Principles for Spa Treatments 37 it even more. Therapists consider the Vital Organ Principle ● THE CORE TEMPERATURE here, and how hard vital organs must work in some con- ditions to keep the body in balance. If a vital organ is PRINCIPLE challenged by disease, then a detoxifying spa treatment is contraindicated. Avoid spa treatments that raise the core temperature if a client’s cardiovascular system, respiratory system, skin, or other tissue Note that the detoxification principle is based on the or system might be overly challenged by heat, or if there are intent of the spa treatment, rather than the established effect comparable medical restrictions. of the spa treatment. As with circulatory intent, there may be little data to verify the effects. But as long as the intent is This principle draws parallels between spa treatments known, it should be considered in the light of a client’s medi- and other activities; it is similar to the Medically Restricted cal condition. Activity Principle. Suppose cardiovascular exercise is contrain- dicated for a spa guest because of his or her condition; the ● THE EXFOLIATION PRINCIPLE heart’s pumping function is compromised. The guest probably also has medical restrictions on hot tubs, saunas, hot showers, If a client’s skin health or overall health is significantly and other activities. The heart cannot provide the increased compromised, do not use treatments involving strong circulation needed to cool the body, so these treatments are exfoliation. contraindicated. This reasoning behind this principle is obvious for skin Another example is a client with lymph nodes missing from health—if a skin condition would be aggravated by exfolia- the axillary (armpit) area, the inguinal (groin) area, or the tion, avoid it. The reasoning is less obvious for overall health. neck, after cancer treatment (see “Lymphedema,” Chapter While it’s possible that exfoliation could help some condi- 20). With potentially compromised lymph flow, there are often tions, it’s also possible that it could aggravate symptoms. If significant restrictions on activities such as saunas and hot nothing else, The Compromised Client Principle applies tubs. Likewise, wraps involving steam, the application of hot here. If used at all with people with complex conditions, stones to a certain area of the body, or other heat treatments exfoliation should be gentle. What is invigorating for a robust may be contraindicated if they raise core temperature or skin person may be fatiguing for someone who is less healthy. The temperature. friction, the demand on the cardiovascular system to increase circulation to the skin, possible detoxification intent, and A good way to get at this possibility in a short spa interview overall nervous system stimulation can be too much for peo- is to ask the guest if there are any medical restrictions on ple when they don’t feel well. If the client is fatigued, frail, activities, and ask specifically about heat treatments. or on strong medications, exfoliation may be too much. At the very least, using gentler exfoliation techniques over less Used with thought and care, the principles in this chapter can of the body is a good idea, and the client’s response should be help the practitioner manage a variety of medical conditions in monitored over a course of treatments to determine whether massage practice. The principles are especially useful when there stronger techniques are appropriate. are gaps in client information or in the therapist’s knowledge. In later chapters, many principles are applied to specific scenarios. Whether general or more specific, massage principles help a mas- sage therapist navigate clinical decision making with confidence. SELF TEST 1. How are principles used in massage contraindications? that client differ from a conversation with a client who has List three ways. had one or two massages, but long before the diagnosis? Which principle are you using? 2. Suppose you have a first-time client with a chronic neck 7. A client informs you of a medical condition that you don’t injury who wants deep neck and shoulder massage. Using know anything about. While he is getting ready on the the Where You Start Isn’t Always Where You End Up table, you ask another therapist what to do. Your colleague Principle, how would you respond to her in the initial ses- advises you “to go with your gut” in order to work safely sion? In subsequent sessions? How would you explain the with him. Which principle or principles can help direct massage plan to this client? you in this situation? 8. A client presents with a condition ending in “-itis,” 3. Why should most massage interviews include a question signifying inflammation. How should you proceed? Which about physical activity? principle most directly applies in this case? 9. If a client reports unstable blood pressure or blood sugar, 4. How is the acute phase of a medical condition different what questions do you need to ask her before working from the chronic phase? with her? Which principle applies to this scenario? 10. Your client’s advanced AIDS has led to the loss of sensation 5. Name three medically restricted activities that are of partic- in his or her feet. What should you do before massaging his ular relevance to a massage therapist in planning a session. or her feet? Which principle are you using in this case? How are these activities relevant to massage planning? 6. Suppose your client has a complex medical condition, such as diabetes, and has received regular massage since his or her diagnosis. How might your conversation with For answers to these questions and to see a bibliography for this chapter, visit http://thePoint. lww.com/Walton.
Chapter 4 Interviewing, Decision Making, and Charting It is the province of knowledge to speak, and it is the the richness of massage therapy. For clients, the experience of being witnessed in this way may be as healing as the other privilege of wisdom to listen. elements of massage therapy. —OLIVER WENDELL HOLMES Verbal history taking, while different from palpation and observation, can be just as rich as the hands-on experience. Massage therapists listen with their hands and hearts, as well Each medical condition, from a broken arm to a life-threat- as their ears. They gather information about clients in various ening illness, is part of a client’s story, and the interview is a ways, for various purposes. They pick up information through perfect setting to learn about it. Obviously it’s not necessary their hands as they travel over the client’s tissues. As they move to learn about a client’s entire medical history, but buried the client’s joints, they note restrictions. They notice postural within it is key, specific information to bring to bear on the habits as the client moves or sits. session. Interviewing for medical conditions, processing the answers, and charting the massage adjustments are the focus This nonverbal information gathering is the classic stuff of of this chapter. These steps are discussed in the order that they massage therapy: human exchanges, beyond words. Through typically occur in practice. these exchanges, therapists engage the body, and also the mind and spirit, in their hands. For many therapists, this is part of The Purpose of the Interview Done professionally and well, the client interview builds ● Identify and document the massage contraindications to apply. rapport, the foundation for the therapeutic relationship (Fig- ure 4-1). It gives the client time to get to know the therapist Interview styles vary across massage settings and between before being touched. In addition, the interview allows the individual therapists. Some therapists conduct only verbal therapist to: interviews, others begin with a written form. No matter how it begins, the interview becomes a conversation: an exchange ● Gather information on the client’s massage experience and of initial questions, a client’s answers, follow-up questions trig- preferences. gered by those answers, more responses, and so on. Through- out, the therapist holds the focus on the client’s health, and ● Learn about the client’s health and establish goals for the how that affects the massage plan. session. Initial Questions The primary tool for the interview is the health intake form It is not practical or necessary to ask about every disease and for massage therapy, also called the client health form, injury. Not all medical conditions are equally affected by massage shown in Figure 4-2. This form covers the basic informa- therapy, and the client health form reflects this. For example, tion needed to bring common massage contraindications to cardiovascular conditions, kidney and liver conditions, and skin light. conditions are mentioned, but immune, lymphatic, and repro- ductive conditions are left out because of space limitations. The ● BALANCING GENERAL AND therapist can capture these conditions with other general ques- tions about chronic disease, symptoms, or medical treatment. SPECIFIC QUESTIONS Explicit mention of some medical conditions is impor- Each therapist finds the right balance of general and specific tant, especially common conditions that are most relevant questions. While general questions take less time to ask, they to massage. This prompts clients, jogging their memory may take more time to answer if they are too open ended. They about their own health. For example, not everyone would may also fall flat; for instance, the question, “Is there anything think to write “varicose veins” under “cardiovascular con- I should know about your health?” is too general. On the other ditions.” Yet, depending on how severe they are, varicose hand, specific questions target some key contraindications, but veins dictate pressure adjustments at the site. By listing a may miss other important information. And too many specific few other key conditions, the therapist increases the chance questions make for a long and tedious interview. of raising important issues before the massage. Initially, a 38
Follow-Up Questions 39 FIGURE 4-1. The client history. The interview is a time for establish- By organizing questions in this way, the therapist approaches ing rapport with the client, and for learning about the client’s story. some of the same key information from different angles. For example, a client with a current injury can be prompted by balance between general and specific questions yields useful questions about inflammation and swelling, pain, injury his- data without making an interview too superficial, repetitive, tory, and activity level. A client with phlebitis might mention or time-consuming. the condition when asked about pain, inflammation, cardiovas- cular conditions, or medical treatment. ● LAYERING AND EMPHASIS Even some follow-up questions, introduced in this chapter, It’s especially important for massage therapists to consider overlap slightly with each other and with initial questions. This factors such as skin integrity, bone and joint stability, changes built-in redundancy decreases the chance of missing some- in sensation, and cardiovascular conditions when planning a thing important in the client’s history. massage session. Because of the emphasis on these issues, they are queried in different ways in order to prompt the client’s ● CUSTOMIZING QUESTIONS memory. This is a layered approach to interviewing. The client health form introduces questions about general health, body How does a massage therapist decide how to ask each ques- systems, and common conditions. There are broad questions tion? This may be dictated by the massage setting, a thera- about chronic and progressive diseases and injuries. The form pist’s own focus on a special medical population, or his or her concludes with questions about medical treatments. own communication style. Therapists can use the questions in this chapter, purchase stock intake forms, or use one provided in school, but it’s best to review each question for relevance and purpose, and then customize a client health form if necessary. In “The History of our History Forms,” a therapist describes the pitfalls of using a generic health form without customizing it (see online at http://thePoint.lww. com/Walton). The questions in this chapter do not need to be read word for word. For the most relaxed, comfortable interview, each therapist can practice asking and following up on questions, in his own words. The best questions are designed or cus- tomized by the therapist, who is clear about what he needs to know about, what he doesn’t need to know about, and how to use the client’s responses. This sense of ownership is important: whatever the setting is, the therapist is in charge of guiding the interview. For each therapist using a set of questions, ease and confidence come from making it his own. The strongest interview is a natural conversation, typically prompted by a written health form. Accuracy of the Client’s Responses One concern therapists share is the possibility of a client Any of these scenarios can result in incomplete or inaccurate providing incomplete or inaccurate information. This is uncom- information. It’s up to the therapist to do his or her best, to be mon, but it does happen, for several reasons: It can be due to alert for inconsistencies, but not try second guess every answer. “form fatigue”—when a client feels her history is too lengthy to Repeating questions verbally, or conducting the entire inter- explain on a form, or she leaves out information, not seeing the view verbally, may remedy the situation. Rewording the ques- purpose behind the questions. Inaccurate or incomplete forms tions may help, and a therapist may need to probe a bit more also result from language barriers, miscommunication, a client’s deeply with some clients than with others. Additional informa- sense of privacy, or even a client’s temptation to withhold infor- tion may come forth as the session unfolds. If the information mation that could jeopardize his or her chances of receiving seems incomplete or inaccurate, if a client’s answers are circu- massage. Sometimes a client is incapable of providing reliable lar, vague, or inconsistent, the therapist works conservatively information, due to extreme stress or mental status changes. until more information is available. Follow-Up Questions A client’s response to a question may provide sufficient informa- eral questions are introduced in this chapter. Follow-up questions tion, or the therapist may need more details. A thorough interview for specific conditions appear in Part II and Part III chapters. usually requires at least a few brief follow-up questions focused on possible massage contraindications. Some follow-up questions In this chapter, follow-up questions on general topics are can be used for a broad range of medical conditions. These gen- grouped by common client presentations such as pain, injury, signs and symptoms, medications, and so on. These all-purpose
40 Chapter 4 Interviewing, Decision Making, and Charting Maria Abutin Massage Therapy 27 Hopedale, Suite 4, Bronxville, NY 10021 Client Health Form for Massage Therapy Phone Name Date of Birth Address Circle areas you would like massage to address: Massage Therapy Have you had massage therapy before? Can you describe it? What did you like or dislike about it? How would you describe your stress level? 0 1 2 3 4 5 6 7 8 9 10 No stress Worst stress imaginable How would you describe your pain level? 0 1 2 3 4 5 6 7 8 9 10 No pain Worst pain imaginable Activities Please describe your daily or weekly activities and any exercise or movement you do each week (e.g., work at desk, computer, or telephone; stand at counter; walk to work; heavy lifting; take care of small children; exercise class; swim, etc.) How would you rate your energy level, on a scale of 0 to 10 (where 0 is no energy and 10 is very high energy)? Health Issues Past or current, dates, any treatment General Health Any areas of pain? Any areas of muscle tension? Any conditions that seem to be caused or aggravated by stress (e.g., headache, back pain, neck pain, or insomnia)? Any inflammation or swelling anywhere in your body? Any changes in sensation (numbness, burning, tingling, etc)? Any areas of current or recent infection? Allergies or sensitivities to certain substances? FIGURE 4-2. A client health form for massage therapy.
Follow-Up Questions 41 Health Issues Past or current, dates, any treatment Skin Any areas of skin sensitivity, irritation, rash, or open skin? Any chronic skin conditions? Any tendency to bruise or bleed? Muscles, bones, and joints Any problems with your joints, such as arthritis? Any muscle problems, such as pain, stiffness, muscle tension, or tendency to cramp? Any bone or spine conditions, such as injuries, osteoporosis, disk problems, or knee problems? Nervous system Any sensation or motor changes? Any numbness, tingling, or muscle weakness? Any pain? Any medical condition that affects your nerves, brain, or spinal cord? Cardiovascular system Have you or a physician ever been concerned about the health of your heart or blood vessels? Circle any of the following you have experienced and describe: Varicose veins Phlebitis (inflamed vein) High cholesterol High blood pressure Atherosclerosis or Thrombosis (blood clot) hardened arteries Pulmonary embolism Heart disease Heart attack Heart arrhythmia Angina Stroke or TIA (transient ischemic attack) Do you take any medications for blood pressure or other cardiovascular issues? Blood conditions Any conditions that affect your blood or blood cells? Respiratory system Any conditions that affect your lungs, nasal passages, or airway? Digestive system Any conditions that affect digestion or elimination? Liver Any conditions that affect your liver function, such as hepatitis, cirrhosis, or other liver disease? FIGURE 4-2. (Continued)
42 Chapter 4 Interviewing, Decision Making, and Charting Health Issues Past or current, dates, any treatment Glands and hormones Any conditions that affect the function of glands, such as the pancreas or thyroid, or hormones? Kidney and urinary Any conditions that affect your kidneys, bladder, or urinary tract? Headache Any history of headache—migraine, tension, or other kinds of headaches? Injuries or accidents Have you ever had a serious injury—car accident, fall, fracture, or sprain? Cancer Any history of cancer or suspected cancer? Diabetes Any history of diabetes or blood sugar problems? Pregnancy Is there any chance that you are pregnant? Chronic conditions Have you had any chronic, recurrent, or ongoing conditions? Progressive or degenerative conditions Have you had any degenerative or progressive (worsening) conditions? Other Any other condition or concern not mentioned here? Medical Treatments Please describe Are you currently or were you recently in a doctor’s care for any condition? Are you taking any medications? Have you taken any strong medications in the recent past? Have you ever had surgery? Any hospitalization in the past 5 years? Any recent, scheduled, or significant diagnostic tests? Are there any activities suggested or restricted by your doctor or other health care professional? FIGURE 4-2. (Continued )
Follow-Up Questions 43 questions often help in a pinch, when the therapist encounters is left to the therapist to determine whether a medical referral, a an unfamiliar medical condition in practice. With answers to massage adjustment, both, or some other action is in order. In the these general questions, the therapist can devise a massage example of swollen glands, a therapist’s concern increases if the plan for that session. client reports that the condition appeared suddenly, persists, is severe, or has no identified cause. Each of these factors calls Of the questions introduced here, the questions about pain, for a medical referral. activity, and medications are the most commonly used. These appear in Boxes 4-1 to 4-3. On the other hand, a clear, identified cause can diminish the concern, as in slight premenstrual puffiness that has persisted More specific follow-up questions, aimed at particular con- for years, or minor swelling on the hand from banging it against ditions, are provided in Parts II and III of this book. something. These require a good judgment call on the part of the therapist, but it is probably safe to massage the premenstrual ● FOLLOW-UP QUESTIONS ABOUT puffiness directly, while the swelling on the hand contraindicates ANY CONDITION pressure levels 3–5 and friction at the site if it is acute. For any condition, familiar or unfamiliar, the therapist can ask ● FOLLOW-UP QUESTIONS these questions to complete the Decision Tree: ABOUT PAIN 1. What are the signs and symptoms of the condition? If it was a long time ago, does it still affect you in some way? A common reason to seek massage therapy is pain, but pain can stem from a variety of causes. How should the therapist 2. Are there any complications of the condition? Does it have determine whether a client’s pain is caused by something an effect on any other organs or tissues in your body?” within the therapist’s scope of practice? Or whether it’s a (Questions 1 and 2 might also be combined as: How does symptom that massage might help relieve? the condition affect you?) If a client reports pain, either on the client health form 3. How is it treated? How does the treatment affect you? or in the interview, several follow-up questions help the therapist learn more about the pain, determine whether Use the client’s answers to complete the left side of a Decision to work with it at the site, adjust massage appropriately, Tree. Compare it to a corresponding pre-made Decision Tree in or suggest a medical referral. The Pain Questions provide this textbook, or to the Conditions in Brief tables at the end of a way to navigate many different client presentations, and each chapter in Part II. If there is no full discussion of this con- they are used repeatedly in practice (Box 4-1). dition in this book, then see Gathering Additional Information, this chapter. ● FOLLOW-UP QUESTIONS ABOUT ● FOLLOW-UP QUESTIONS ABOUT INJURIES SIGNS AND SYMPTOMS The role of massage therapy in treating injuries may vary For any sign or symptom, such as rash, swelling, pain, or discom- according to state and provincial regulations, and be subject fort, the therapist can ask: to different levels of training. These questions are generally helpful, no matter what the context is: 1. Do you know what the cause is? 2. Have you seen a doctor for this condition? 1. Where is your injury? Have the client point to it and establish the site. It is advisable Use the first question to apply the Ask the Cause Principle from to document the site in the client record. Chapter 3. Complete a Decision Tree for the causative condi- 2. When did it happen? Has it happened before? tion. If the condition is the result of a medication, complete the Work conservatively with a recent injury, and provide a medi- Medical Treatment and Effects of Treatment boxes and apply cal referral where necessary. With a recurrent injury, the client the Medication Principle. already knows how to get better, knows the injury will probably heal and how long it will take, and may even have experience It may be that the cause itself is a massage contraindica- with how massage helps. With this information, it’s easier for tion, or calls for more follow-up to fill out the tree. Suppose you to provide massage that will help, rather than aggravate the the client answers “yes” to a question on the health form about injury. In general, it’s easier to predict a massage outcome for a swelling because he or she has swollen glands. Swollen glands familiar condition than a new one. under the jaw contraindicate pressure and circulatory intent at 3. Have you seen a doctor about it? (This especially applies to the site. But the cause is usually infection, which contraindi- cates general circulatory intent as well. a recent injury.) If so, what was the diagnosis? If the client has seen his or her physician and has a diagnosis, The Ask the Cause Principle. Consider the cause of sign or determine if there are any massage contraindications. If the symptom, as well as the sign or symptom itself, when making client has not seen his or her physician, then apply the Recent a massage plan. Injury Principle. The question about whether the client has seen a physi- The Recent Injury Principle. Recent injuries, or injuries cian can be used for two purposes: The first is to find out the that have not been seen by a physician, should not be causative condition and adapt to it. For many reasons, includ- treated with massage therapy, or massage therapy should be ing lack of access to health care, people self-diagnose and conservative. self-treat their own conditions. For conditions that could be serious, a therapist needs a physician’s diagnosis; otherwise, it
44 Chapter 4 Interviewing, Decision Making, and Charting BOX 4-1 THE PAIN QUESTIONS 1. Where is the pain? Have the client point to it, so the site is clear. It’s advisable to document the area in a client record. 2. Describe the pain; what does it feel like? (Dull, achy, sharp, stabbing, radiating, shooting, burning, tin- gling, and so on.) Does it appear suddenly? On a scale of 0–10, with 0 being no pain and 10 being the worst possible pain, how would you rate your pain? Pain with “nervy” qualities—sharp, stabbing, radiating, shooting, burning, or tingling—requires a medical referral. But a dull, achy pain may be muscular in origin and amenable to massage. However, if dull, achy pain is chronic or persistent, a medical referral is advised. Review the Physician Referral for Pain Principle in Chapter 3. Use the client’s answers to the verbal analogue (0–10) scale for before and after assessments, to determine whether massage is helping. Also, pain that is above a level 2, or is very disturbing to the client, is cause for a medical referral. 3. Is there any numbness or tingling, or weakness with the pain? If yes, refer the client to his or her physician, as these symptoms need urgent or immediate attention. The Physician Referral for Pain Principle. If a client’s pain has specific qualities, such as sharp, stabbing, radiating, or shooting pain, or if the pain is accompanied by tingling, numbness, or weakness, refer the client to a physician. 4. Would you describe the pain as stable or unstable? Unstable means that slight movements or position changes bring on sudden or strong pain. If the pain is unstable, the client should see a physician. If you must provide massage in the moment, minimize distur- bance to the area: limit pressure and joint movement, and use careful positioning. Review the follow-up questions about injury in this chapter as well as the Pain, Injury, and Inflammation Principles in Chapter 3. The Unstable Tissue Principle. If a tissue is unstable, do not challenge it with too much pressure or joint movement in the area. 5. How long have you had it? Has it happened before? You can get a sense of how familiar, recurrent, and well managed the pain is, and whether the client has her own methods and a track record of relieving the pain herself. With unfamiliar pain of recent onset, be more cautious; people often feel anxiety that can aggravate pain, and if strong massage temporarily worsens the condition, it could be more problematic than for someone who can manage the pain. If the client has prior experience of the pain and has treated it successfully, she is likely to be less anxious about it. The New, Unfamiliar, or Poorly Managed Pain Principle. Massage for a client with new, unfamiliar, or poorly managed pain should be more conservative than massage for a client with a familiar, well-managed pain pattern. 6. Does it interfere with your usual level of function? Does it restrict any positions or activity? A medical referral is necessary if the pain is disabling. In milder cases, massage is usually okay, but monitor massage outcomes over time. If several sessions of massage fail to provide relief, the client should see his or her physician. 7. Does gentle stretching or movement provide relief, or does it aggravate the pain? If it relieves pain, massage is also likely to help. If it aggravates pain, be much more cautious. 8. Do you know what causes or caused the pain? Working backward on the tree, investigate the cause for any needed massage adjustments. 9. Have you brought it to the attention of your doctor? This information is always useful, but is especially pertinent to Questions 2, 3, 4, and 6, above. Without a diagnosis, proceed cautiously. 10. In general, how do you manage the pain? What aggravates it? What relieves it? Use this information to try to avoid aggravating factors such as certain positions in the session, and to optimize relieving factors such as positions and pressure from the client’s daily life. You can get a sense of which muscles are involved. Advanced massage therapists can use this information to evaluate an injury. 11. Does it limit your activities? If so, because it’s stiff, or because sudden, strong pain occurs with movement? (Continued )
Follow-Up Questions 45 (Continued ) If the pain limits movement by coming on suddenly and strongly, make an urgent medical referral (see Question 2, above.) If it is just stiff, monitor the massage results over time, as massage may help. 12. Have you used massage for the pain? If so, has massaged helped or aggravated the pain? If you can, describe what it is about massage that has helped or worsened the pain—certain strokes or movements, pressures, positions, or focus on some areas? If the client has not used massage for the condition, approach conservatively for the first session, and monitor the results since there is no massage track record for this condition. If the client has used massage, draw on the history of aggravating and relieving factors to design the current session. This is in keeping with the Previous Massage Principle. The Previous Massage Principle. A client’s previous experience of massage therapy, especially massage after the onset, diagnosis, or flare-up of a medical condition, may be used to plan the massage. 4. Were any tests performed, such as an X-ray? The Sensation Principle. In an area of impaired or absent It’s important to know there’s no fracture or other unstable tis- sensation, use caution with pressure and joint movement. sue before applying pressure or moving joints in the area. 5. How was it treated? If the answer is any other sensation, such as burning, or Refer to the “four medication questions” in Box 4-3, this chapter. something unfamiliar, gentle massage in the area may be 6. Are there any medical restrictions on activities, or recom- okay, but go to questions 3 and 4 first. If the client knows the cause, complete the Decision Tree for the cause and investi- mended activities? gate any massage contraindications. If the client has not told Compare these activities to the elements of massage. If there his or her physician about the problem, strongly encourage are activity restrictions, apply the Medically Restricted him or her to do so. Be extremely gentle in the area until Activity Principle. If there are recommended activities, com- she has further information from his or her physician. If the parable massage pressure and joint movements are probably sensation change is accompanied by muscle weakness, other permissible and may be helpful. nervous system symptoms, or other unfamiliar symptoms, 7. Is there any pending insurance or worker’s compensation then an urgent or immediate medical referral is the best action. claim, or possible litigation arising from this injury? Consider your own skill level in injury work, the timing, ● FOLLOW-UP QUESTIONS ABOUT and the client’s ongoing assessments by a physician in doing INFECTION massage in this case. Avoid doing anything—usually joint movement and pressure levels 3 and above—that could 1. What is the nature of the infection? What is affected? be perceived as causing or aggravating the injury. On the 2. Has it been diagnosed? other hand, if the client’s injury has been documented by a 3. Is it something you need to take precautions for, to avoid physician, you have injury treatment skills, and your work is part of an approved or integrated treatment plan, then infecting others? massage does not have to be so cautious. 4. Are you having any fever or chills? Do you continue to feel The Claim or Litigation Principle. If a client’s recent injury worse, or are you feeling better? involves an insurance claim or litigation, do not complicate the clinical picture with massage that could affect the area. Use these follow-up questions to get at several issues: where the infection is, whether you are at risk of contracting it, After completing injury questions, the therapist continues whether it’s acute, and how to work with the client if it is with the questions about pain (this chapter). If a client has advisable. impaired or absent sensation and the pain questions don’t apply, it is important to consult the physician to learn which If your client is fighting an infection, for example, a cold or structures are injured and how to safely apply massage. flu, he or she is not a good candidate for massage with general circulatory intent. This is especially true if it’s acute, and he or ● FOLLOW-UP QUESTIONS ABOUT she is experiencing fever or chills. Follow the Compromised Client Principle. SENSATION CHANGES The Compromised Client Principle. If a client is not feel- 1. Where is the sensation change? ing well, be gentle; even if you cannot explain the mechanism 2. Describe the feeling. behind a contraindication, follow it anyway. 3. Do you know the cause? 4. Have you brought it to the attention of your doctor? On the other hand, if your client is past the peak of infection 5. Is this accompanied by any weakness in your muscles, or and has been feeling better for a few days, he or she is probably better able to tolerate general circulatory intent. other nervous system symptoms? If the answer to question 2 is numbness or loss of sensation, follow the Sensation Principle.
46 Chapter 4 Interviewing, Decision Making, and Charting Suppose the infection seems minor, such as a very slight from X-rays about a fracture, or from blood tests about a client’s swelling around a hangnail, minimal discomfort, and no other vulnerability to infection. Massage modifications such as pres- symptoms. Avoid contact at the site, and circulatory intent on sure, or infection control precautions, flow from these. that limb, but if there are no chills or fever, general circulatory intent elsewhere is probably not contraindicated. However, if If the client reports a recent, scheduled, or significant test, the swelling is uncomfortable, or there are other signs of acute the follow-up questions are: infection, see “Lymphangitis,” Chapter 13. 1. What were (or are) they testing for? With the name of the infection and the area affected, you If the client is scheduled for an important test, or has had it, but is can establish whether you are at risk of contracting it during still waiting for test results, then his or her doctor could be investi- a massage. Some fungal, bacterial, or viral infections of the gating a worst-case or best-case possibility. Apply the Waiting for skin, such as ringworm, impetigo, and herpes, are transmis- a Diagnosis Principle until the actual results come back. sible by contact. Other conditions, such as athlete’s foot, are also transmitted by contact, but infecting others is not easy The Waiting For A Diagnosis Principle. If a client is sched- unless they are immunocompromised or particularly sus- uled for diagnostic tests, or is awaiting results, adapt massage ceptible. Other parasitic infestations, such as lice or scabies, to the possible diagnosis. If more than one condition is being are highly communicable, regardless of everyone’s immune investigated, adapt massage to the worst-case scenario. status. And some respiratory infections, such as the common cold, are transmissible by contact with skin or fluids from 2. What were the findings? mucous membranes. Learn about the client’s infection, deter- Adapt the massage to the new diagnosis or any change in mine where it is, then check in this book or other resources health status. If the client has a life-limiting condition such for the level of risk to ensure that contact and massage are as cancer or advanced heart disease, ask this question gently, safe for you. If in doubt, contact the health department in with a warm and matter-of-fact tone. It’s possible that every- your area; a nurse can provide useful information about touch one in the client’s life is asking the same question, and that the and communicable disease. client feels burdened by keeping them up to date, or by not always being able to provide good news. ● FOLLOW-UP QUESTIONS ABOUT 3. What was the procedure (or anticipating the procedure) ALLERGIES AND SENSITIVITIES like for you? Use this last question judiciously; it might not be appropriate 1. Are you sensitive to any of the following ingredients in the to ask of all clients, or for minor procedures. But by asking, lotion/oil I use? you can learn useful information: Did he or she have to hold still for the procedure? Was his or her body in a certain posi- List the ingredients. Nut oils and preservatives are common tion? Did it cause him or her pain or discomfort, something offenders. If the client has a history of reaction to any known that massage might address? Is it stressful to anticipate the ingredient, avoid using it. test, or to wait for the results? 2. What happens when you have an allergic reaction or By asking these questions, you offer the client an sensitivity? opportunity to say how the experience affected him. Some Use this question to identify signs of a reaction if they arise during diagnostic tests are painful and stressful, cause concern to the session and discontinue using the lotion or oil if so. the client’s loved ones, and are part of life-changing experi- 3. Do you have a favorite lotion or oil you’d like me to use for ences of injury or illness. Along with physical side effects, procedures can be surrounded by stress—the hope of good massage? news to report, and the need to take care of others when Within limits, you might be able to use a lotion or oil the client the news is bad. brings in, one with a known track record. This is advisable if the client is especially sensitive, or is sensitive to multiple factors. Important client experiences lie within this line of ques- tions about diagnostics. Essential information for massage ● FOLLOW-UP QUESTIONS ABOUT planning may emerge, as well. ACTIVITY AND ENERGY ● FOLLOW-UP QUESTIONS In determining contraindications, the therapist can draw ABOUT MEDICATIONS on elements that are common to both exercise and massage therapy. Questions about activity level, activity tolerance, and Many massage clients are taking prescription or over-the- activity restrictions are some of the most useful in predict- counter medications, and some are taking several. The ing the client’s response to massage. Together with a client’s dizzying array of brand names, generic names, chemical energy level, this information can help the therapist plan a actions, and side effects can be intimidating. The informa- massage session of appropriate strength (Box 4-2). tion expands as new drugs are added to the market. Com- plete command of this information would be difficult, but ● FOLLOW-UP QUESTIONS ABOUT therapists practicing at the basic level can use thoughtful questions and several resources to determine the massage DIAGNOSTIC TESTS implications of a client’s medications. There are excellent textbooks on this topic (Wible, 2009; Persad, 2001), listed in One valuable question—Have you had any recent, scheduled, the bibliography. or significant diagnostic tests?—helps establish how the physi- cian is monitoring the client’s health, and what their concerns Much of the time, the massage and medication issues can be are. This question may be asked of all clients, or of any client captured with four medication questions. In many cases, a client’s who reports a symptom or medical condition. The questions about diagnostic tests help the therapist identify massage contraindications. There might be information
Qualities of a Good Interview 47 BOX 4-2 THE ACTIVITY AND ENERGY QUESTIONS 1. What is your activity level? Can you describe your average movements and activities each day? Each week? This question gives you a sense of how the client’s medical condition or medical treatment affects his or her movement hab- its and activity, and how well he or she might tolerate massage. Apply the Activity and Energy Principle (see Chapter 3). If you are evaluating the client closely for muscle tension patterns and restrictions, this information is also useful to determine any activities or movements that contribute to the muscle tension. Note that sometimes this question can make an individual feel uncomfortable and guilty about not exercising, and tempted to report exercise above his or her true levels. Ask this question in a neutral tone, without judgment. “Can you tell me what kinds of things you were able to do yesterday and today?” Probe gently for the information. 2. How is your tolerance of activities? Do you stay pretty strong or do you feel fatigued from your schedule and activities? Use the client’s responses to gauge the best strength of the massage. A high activity level might reflect necessity (such as working full-time, or taking care of children) rather than true energy reserves. Even if your client keeps an impressive sched- ule, if he or she is overwhelmed by fatigue from his or her health, work, or family responsibilities, massage should be gentle. 3. Are there any medical restrictions on your activities? If your client’s physician has restricted his activities because of a condition or medical treatment, then adjust the mas- sage, in kind: usually joint movement or general circulatory intent should be limited. The Medically Restricted Activity Principle. If there are any medical restrictions on a client’s activities, explore and apply any equivalent massage contraindications. If spa services such as hot wraps are being considered, ask specifically whether cardiovascular exercise, heat applications, or raising core temperature is restricted, and see “Principles for Spa Treatments,” Chapter 3. 4. Can you describe your overall energy level? If it is low, are there good or bad times of the day or week? If the client’s energy level is compromised by illness or medical treatment, apply the Activity and Energy Principle. Establish whether there are cyclical symptoms to work around or address. You might try timing massage sessions during low points if massage seems to energize the client. Or provide massage at end of day when the client’s energy is no longer needed for daily activities, and massage can help his or her sleep. If the client prefers vigorous massage, you might sched- ule the session for expected higher energy times, when he or she might be able to tolerate slightly stronger work. answers to these standard questions provide enough information Many medications and procedures appear in the Full to proceed with the massage session in the moment. Decision Trees in Parts II and III. Each tree is devoted to a medical condition, and shows some of the most common These four medication questions (Box 4-3) have an addi- therapies for that condition. Often, there are too many side tional use: Once the word “procedure” is substituted for effects to list them all, but the side effects that are most rel- “medication,” they become “the four medical procedure evant to massage planning are listed. Treatments and their questions.” These address other kinds of treatments such effects point to massage therapy guidelines on the right side as surgery, laser or radiation therapy, and physical therapy of the tree. protocols. Qualities of a Good Interview No matter how long an interview is, the dialogue at the start of Some of these qualities seem to conflict: How does a thera- a massage can be pivotal for the session. The conversation allows pist establish rapport, collect thorough health information, the therapist and client to get to know one another, exchange and maintain an unhurried pace in a short amount of time? important information, and plan the massage. These are quali- This may take practice: by conveying interest, using a relaxed, ties of a good interview: friendly tone, and gently steering the interview in the direction of the necessary information. ● Thorough ● Short duration Limiting the interview length can be challenging when the ● Focused client health form seems long, but in reality, most interviews can ● Sets clear expectations be accomplished in 10–15 minutes. More time may be neces- ● Unhurried sary in student clinics or in settings specializing in medically ● Establishes rapport complex client populations. With practice, most therapists can move quickly through the information, because they
48 Chapter 4 Interviewing, Decision Making, and Charting BOX 4-3 THE FOUR MEDICATION QUESTIONS 1. How do you spell it? Having the correct spelling helps you look it up. Even if your client doesn’t know the correct spelling, a close approxima- tion will enable you to look up the drug in a book, on the Internet, or in a product information reference. Be careful of similar-sounding brand names, though, such as Celebrex and Celexa, two very different drugs with different properties. 2. What is it for? By itself, the condition being treated may contraindicate one or more massage elements. Investigate whether this is so. 3. Is it effective? Establish whether the condition has resolved, or if there are still problems such as signs, symptoms, or effects on tissue function. Many medications control symptoms but do not address the underlying cause. Adapt massage to any remaining problems. 4. How does it affect you? Are there any side effects or complications of this medication? Common side effects of medications, such as nausea, fatigue, hypotension, and digestive disturbances, require their own massage adjustments. Find out how the drugs are affecting your client, and adapt the massage plan accordingly. Used well, these four questions satisfy the Medication Principle (see Chapter 3). When the format is used to ask about a medical procedure such as surgery or laser treatment, it satisfies a similar principle, the Procedure Principle (see Chapter 3). The Medication Principle. Adapt massage to the condition for which the medication is taken or prescribed, and to any side effects. recognize areas that require more focus, and areas that are the massage table? Right now I need to know some less important. quick information about something else you mentioned so we can plan the session without cutting into your mas- Because most clients prefer to spend the time actually sage time—I’m aware that it’s already 5:20. receiving massage than talking about it, therapists should set an approximate time frame for the interview, and let the client Or even give the client a choice: know the purpose behind the questions. This helps the client to relax, knowing that the massage treatment is forthcoming: It seems like you have more to say about this condition. I’m aware of the time, and the need to begin the mas- Thank you for filling out this form. The information you sage in order to finish by 6:30. If you want, we can keep gave me is very helpful. I’ll be focusing with you for a talking and shorten the massage by a few minutes. Or, I few minutes on the things that help me plan your mas- can gather the other information I need right now, and sage session. We’ll talk for about 15 minutes, plan your we can continue this conversation after you’ve gotten on session together, and make sure we have you ready on the table. Which would you like? the massage table around 5:15 so we don’t interfere with any of your hands on time. In the last example, the client may choose to continue talk- ing, but the therapist can relax, having defined the overall Some clients, when prompted by health questions, may talk time limits, and knowing that the client probably needs more at length, prolonging the interview. It is up to the therapist to conversation in order to be comfortable. This can contribute manage the interview, and there are gracious ways to guide the to rapport. When delivered in a relaxed manner, the therapist discussion when it goes on too long: conveys interest in the client, without sacrificing the point of the interview: a safe, effective massage session. Since we just have a couple of minutes left, tell me how these two medications affect you, and what they are for. That said, therapists who set their own schedules may opt Then we can get started on the massage. for a longer interview, preferring the time to ask open-ended questions and get to know the client before beginning the Or massage. Therapist’s Journal 4-1 describes a less structured interview, focused on the client’s experience as well as the I wonder if I can jump in for just a moment. How about therapist’s need for information. if we continue this conversation after you’ve gotten on Processing and Decision Making How does the therapist use the information that emerges questioning, and an excess of information, there may be from the client interview? A health history can contain gaps in information. Swiftly and thoughtfully, the therapist an overwhelming amount of information, especially from needs to come up with a massage plan, using the right an older adult with multiple conditions, yet not all of the massage guidelines. There are three steps in this decision- information is relevant to massage. Even after thorough making process:
Processing and Decision Making 49 THERAPIST’S JOURNAL 4-1 A Client-Centered Health History I’m not a big fan of generic history forms. In the beginning of massage therapy study or practice, I think they are nec- essary in order to provide a framework and make sure everything is covered. But after 20 years of interviewing people in nursing and massage therapy, I have honed the process enough so that I do a more narrative, open-ended history taking. In my practice, I begin by asking clients what brought them to massage, and asking more about their reasons for coming. What comes out can take you in a very different direction than a generic form. If they’re comfortable, clients may tell you about the stressors in their life. Sometimes asking about stress outright, to rank their stress level on a 1–5 scale, can prompt this process. I’ve provided massage to a lot of different populations who may feel alienated by a form, whose tolerance of bureaucracy may be limited. I’ve worked with homeless people, folks with mental health problems, people with substance-abuse problems, and so on. I also work with many people for whom English is not their first language, and some of them feel lost and confused in bureaucratic systems that insist on more forms to fill out. Often with people who might feel marginalized by a written form, I’ll start with getting them to move, looking and touching the area of their complaint, and pointing at diagrams of the body to indicate what is going on. We move quickly to the reason they want massage therapy, making it relevant. I find out the other things on a history form along the way, but with- out necessarily ticking through a checklist. The stressors they talk about might be a five-hour wait in a welfare line, a methadone clinic that is closed, or a new symptom of HIV infection. There’s a good argument for forms that are gender-specific and age-specific. Adolescents and young adults may have more body image issues for me to consider; for women who have given birth, I’ll ask about postpartum issues that can linger long after the last baby was born. With middle-aged and older adults, I make sure I attend to chronic, degenera- tive, and age-related disease so that I don’t miss anything important. As a massage therapist, I feel responsibility: for some people, massage therapy is a point of entry into the health care system. We need to be vigilant, looking for common diseases and red flags, so that we can refer the client appro- priately to other health care professionals when necessary. The most important thing is for therapists to listen carefully and come to the interview without judgment. They need to show unconditional positive regard in every exchange with clients. They need to demonstrate that they have listened by asking good follow-up questions in the interview, and then acting on the client’s major concerns during the massage session. An intake interview needs to be client centered, not just therapist centered. Whichever method the therapist uses to gather data, the client should feel comfortable. Isobel McDonald Van couver, BC, Canada 1. Sort and prioritize the information. this book—either a chapter, section, or Conditions in Brief— 2. Apply appropriate principles and Decision Trees to the for follow-up questions and massage contraindications. scenario. Let’s consider the question about surgery on the client 3. Gather additional information if necessary. health form. Having asked three clients about their history of surgery, the therapist might find out the following: ● SORTING AND PRIORITIZING 1. A 57-year-old client had surgery to remove his tonsils at CLIENT INFORMATION age 5. When a great deal of history emerges in the health history, how 2. A 36-year-old client had a procedure 2 years ago to unblock does a therapist wade through it? Sorting and prioritizing are her fallopian tubes. necessary during the interview, to guide it to the relevant top- ics, and afterward, to generate massage guidelines. 3. A 43-year-old client had back surgery 14 months ago. A Decision Tree provides one way to sort information, and Does this reflect impaired function or stability of an organ or Chapter 1 provides guidance for the interview using a pre- tissue? This is a good test question for each of these scenarios. made Full Decision Tree, or generating an individualized one In the first scenario, a tonsillectomy 52 years ago would not in the moment. have appreciably affected the function or stability of any organ or tissue, and would have no effect on the massage plan. Prioritizing is a skill that comes with practice, and becomes second nature, even on a tight schedule. It can help the thera- In the second scenario, a procedure to unblock fallopian pist to ask himself a few key questions: Does this information tubes has little bearing on the massage itself, as there is no cue me to any massage principles from Chapter 3? Is it pos- specific principle or contraindication to apply. Nothing within sible that there is impaired function or stability of an organ or reach is likely to be inflamed or injured. However, a follow- tissue? Is something inflamed, or injured? Is it something I’ve up—Have you had any related procedures or medications more never heard of? Is it something sudden, new, recent, unfamil- recently?—might begin a conversation about a current struggle iar, poorly understood, or pending a diagnosis? If the answer to with fertility treatment, the related stress, or an upcoming each of these common-sense questions is no, then it may not procedure that could have massage contraindications (see require follow-up. If the answer is yes, the therapist consults “Female Infertility,” Chapter 19). The client might even state a therapeutic goal—reduced stress—to help her cope with the
50 Chapter 4 Interviewing, Decision Making, and Charting treatments. During these conversations, the therapist can use Thanks to the activity and energy questions (see Box 4-2) the opportunity to build trust and rapport with warmth, lack of and the four medication questions the therapist learns of no judgment, and careful listening. significant complications, and few medications. The thera- pist crosses out the middle branch of the tree for this client, In the third scenario, a conversation about the surgery could and part of the bottom branch. A moderateto vigorous mas- alert the therapist to tension patterns to guide the massage, any sage session is appropriate, with general circulatory intent. stabilizing metal in the back on which to avoid pressure, old This session is ideal for the client’s actual health picture and and recurring injuries to bear in mind, and current pain levels activity level. or restricted mobility. The therapist might draw on one or more principles from Chapter 3, such as the Previous Massage The Activity and Energy Principle. A client who enjoys regular, Principle, to develop a plan for the session. moderate physical activity or a good overall energy level is better able to tolerate strong massage elements—including ● USING THE INTERVIEW, general circulatory intent—than one whose activity or energy level is low. PRINCIPLES, AND DECISION TREES A therapist working under time constraints might not be able How does a therapist use the interview along with the Deci- to complete a tree for each condition, but may rely on a princi- sion Tree, and the principles from Chapter 3? These tools ple or two to determine what to do. Either way, good questions reinforce each other, and can be used in different sequences. for the client supplement the other decision-making tools in Figure 4-3 shows different ways to use these decision-making this book. By using the massage principles, the Decision Tree, tools. As shown in Figure 4-3A, the Full Decision Tree sug- and the interview in just the right balance, a therapist is able to gests questions to ask about a client’s condition, and a therapist customize massage for each client’s health and needs. can go quickly down the left side of the tree, asking about each aspect of it. Or, checking principles, such as those about ● GATHERING ADDITIONAL inflammation, pain, injury, and medical treatment, the thera- INFORMATION pist questions the client about each of these topics. Most clients are able to provide reliable, complete information In another sequence in Figure 4-3B, the interview brings about their own medical conditions, but even after a thorough out health information that can be sorted into boxes on the interview, the therapist may need to look something up to left side of an Individual Decision Tree, then checked against determine the best massage plan. This may occur after an initial a pre-made tree. Key health information often emerges in a phone conversation with the client, after the interview, or even more or less random fashion, so the therapist might start any- between sessions. Often a therapist has only a few minutes to where on the tree, then move backward, forward, and upward. hurriedly gather information while the client gets on the massage Here is an example of this: during the conversation, a piece of table. Three places to turn to for more information are Massage information pops up, such as a drug the client is taking. The therapy literature, patient education literature, and, in some therapist uses the four medication questions to learn more cases, the client’s physician or nurse. about the drug, discovering that it controls blood sugar, and that the client has diabetes. Questioning the client further, he Massage Therapy Literature or she sketches out an individual Decision Tree, then checks it against a full, pre-made tree for diabetes (see Chapter 17) in The chapters in Part II and III of this text provide Decision this book to complete the right side. Trees, Interview Questions, Massage Therapy Guidelines, and Conditions in Brief. All are designed for quick consultation. Often, the information that comes out in the interview injects a healthy dose of reality into the clinical thinking pro- Several massage therapy textbooks are useful sources of cess, as shown in Figure 4-3C. Suppose a client mentions that medical and massage information. Therapists can draw on books he or she had a heart attack 3 years previously. According to on pathology, medications, concerns in special settings, and the full Decision Tree for heart disease, one complication is special client populations. The bibliography (online at http:// heart failure—an impaired ability to pump blood (see Chapter thePoint.lww.com/Walton) lists many of these sources (Werner, 11). This serious impairment, on the middle branch of the 2009; Wible, 2009). Decision Tree, contraindicates general circulatory intent. This follows the Filter and Pump Principle. Patient Education in Print and Online The Filter and Pump Principle. If a filtering organ (liver, kid- When a patient is diagnosed with a medical condition, he or she ney, spleen, or lymph node), or a pumping organ (the heart) is often receives literature about it from his or her nurse as part of functioning poorly or overworking, do not work it harder with patient teaching. Booklets, pamphlets, and Web sites that inform massage that is circulatory in intent. patients and families about health conditions offer accessible and helpful information for therapists, even if there is no explicit Yet, as the interview continues, the therapist learns about mention of massage contraindications. Without mentioning mas- the client’s heart function, activity level, and activity tolerance. sage therapy directly, these resources often have practical guid- After the heart attack, the client gradually returned to a very ance for the massage setting. Here are some examples: high level of activity; running several miles a week; doing heavy, supervised workouts at the gym, taking aerobics classes. In this 1. A Web site on stroke describes common areas of impaired case, the Activity and Energy Principle prevails, effectively sensation. Applying the Sensation Principle, the therapist overriding the Filter and Pump Principle.
Processing and Decision Making 51 A. Full, pre-made Interview Massage ?? principles decision tree yes The Recent Injury Principle Diabetes Massage concern and actions ? Lorem ipsum dolor sit amet, consectetur adipiscing elit. Fusce faucibus Medical Information Ut non tristique ipsum. Proin ...! adipiscing condimentum. Ut eget ipsum turpis, ut facilisis turpis. In odio nunc, commodo elementum ultrices. dignissim sit amet ornare ac, mattis non nunc. Vivamus eu justo purus, eu Essentials lobortis mi. Morbi quam felis, rhoncus sit amet porttitor et, aliquet non enim. Pellentesque feugiat, sem sed posuere Aenean fermentum, lectus at mattis tempus, leo tellus congue felis, pretium posuere, ante erat volutpat tortor The Inflammation Principle auctor nisi lectus a mauris. In hendrerit turpis purus eu lorem. Nam condimentum pellentesque eros quis gravida. Vivamus egestas tempus Donec vitae ante ut erat facilisis lobortis. Aenean fermentum mollis eros et pharetra. Nam in justo ut tortor aliquam varius. Nullam ipsum ipsum, tempor Nulla pharetra semper neque vel rhoncus hendrerit. suscipit tristique in, volutpat ut mauris. Sed nec vehicula libero. Nunc augue Fusce porta est et quam feugiat elementum The Medication Principle Pellentesque hendrerit dolor eu elit porttitor venenatis laoreet. Nulla vitae augue sapien. Morbi tristique ullamcorper odio, a euismod velit rhoncus quis. Aenean molestie sollicitudin nibh, ac imperdiet accumsan justo sollicitudin augue viverra in. Integer et lectus ac magna viverra auctor. Etiam tincidunt dictum mollis. Complications Vestibulum in enim massa Sed ante lectus, consequat malesuada porta Suspendisse quis massa nunc rhoncus, aliquet ut nisi. Vivamus tortor nulla, suscipit ac congue sed Cras tortor urna, venenatis a congue Nullam ultricies sodales dui, sit Euismod, aliquet id ligula amet pulvinar leo elementum ac Medical treatment Effects of treatment Etiam ipsum tortor Donec dignissim Placerat id pretium et tortor sed ligula Donec bibendum, erat id porta Mollis nec libero ultricies, ante lectus hendrerit sapien Pretium sed congue massa varius Ac fermentum nunc mauris vel magna Donec a sem B. Individual Full, pre-made Interview ?? decision tree decision tree no Diabetes Massage concern and actions Diabetes Massage concern and actions ? Medical Information Ut non tristique ipsum. Proin Medical Information Ut non tristique ipsum. Proin yes! commodo elementum ultrices. commodo elementum ultrices. Essentials Essentials Pellentesque feugiat, sem sed posuere Aenean fermentum, lectus at mattis Pellentesque feugiat, sem sed posuere Aenean fermentum, lectus at mattis tempus, leo tellus congue felis, pretium posuere, ante erat volutpat tortor tempus, leo tellus congue felis, pretium posuere, ante erat volutpat tortor auctor nisi lectus a mauris. auctor nisi lectus a mauris. In hendrerit turpis purus eu lorem. In hendrerit turpis purus eu lorem. Donec vitae ante ut erat facilisis lobortis. Aenean fermentum mollis eros et Donec vitae ante ut erat facilisis lobortis. Aenean fermentum mollis eros et Nulla pharetra semper neque vel rhoncus hendrerit. Nulla pharetra semper neque vel rhoncus hendrerit. Fusce porta est et quam feugiat elementum Check against Fusce porta est et quam feugiat elementum Pellentesque hendrerit dolor eu elit porttitor Pellentesque hendrerit dolor eu elit porttitor accumsan justo sollicitudin accumsan justo sollicitudin Complications Vestibulum in enim massa Complications Vestibulum in enim massa Sed ante lectus, consequat malesuada porta Suspendisse quis massa nunc Sed ante lectus, consequat malesuada porta Suspendisse quis massa nunc rhoncus, aliquet ut nisi. Vivamus tortor nulla, suscipit ac rhoncus, aliquet ut nisi. Vivamus tortor nulla, suscipit ac congue sed congue sed Cras tortor urna, venenatis a congue Cras tortor urna, venenatis a congue Nullam ultricies sodales dui, sit Nullam ultricies sodales dui, sit Euismod, aliquet id ligula amet pulvinar leo elementum ac Euismod, aliquet id ligula amet pulvinar leo elementum ac Medical treatment Effects of treatment Etiam ipsum tortor Medical treatment Effects of treatment Etiam ipsum tortor Euismod, aliquet id Placerat id pretium et Euismod, aliquet id Placerat id pretium et ligula Donec bibendum, ligula Donec bibendum, erat id porta erat id porta Mollis nec libero ultricies, ante lectus Mollis nec libero ultricies, ante lectus hendrerit sapien hendrerit sapien Pretium sed congue Pretium sed congue massa varius Ac fermentum nunc massa varius Ac fermentum nunc mauris vel magna mauris vel magna Donec a sem Donec a sem C. Interview Full, pre-made ?? decision tree no ? Heart disease Massage concern and actions yes! Medical Information Ut non tristique ipsum. Proin commodo elementum ultrices. Essentials Pellentesque feugiat, sem sed posuere Aenean fermentum, lectus at mattis tempus, leo tellus congue felis, pretium posuere, ante erat volutpat tortor auctor nisi lectus a mauris. In hendrerit turpis purus eu lorem. Donec vitae ante ut erat facilisis lobortis. Aenean fermentum mollis eros et Nulla pharetra semper neque vel rhoncus hendrerit. Fusce porta est et quam feugiat elementum Pellentesque hendrerit dolor eu elit porttitor accumsan justo sollicitudin Complications Vestibulum in enim massa Sed ante lectus, consequat malesuada porta Suspendisse quis massa nunc rhoncus, aliquet ut nisi. Vivamus tortor nulla, suscipit ac congue sedl Cras tortor urna, venenatis a congue Nullam ultricies sodales dui, sit Euismod, aliquet id ligula amet pulvinar leo elementum ac Medical treatment Effects of treatment Etiam ipsum tortor Euismod, aliquet id Placerat id pretium et ligula Donec bibendum, erat id porta Mollis nec libero ultricies, ante lectus hendrerit sapien Pretium sed congue massa varius Ac fermentum nunc mauris vel magna Donec a sem FIGURE 4-3. Decision-making tools for massage therapists. The interview, Decision Tree, and principles can be used in various ways. (A) A Full Decision Tree and one or more massage principles guide the interview. (B) The therapist uses the interview to create an Individual Decision Tree, then checks it against a Full Decision Tree for completeness and accuracy. (C) A client’s answers to interview questions are used to cross out irrelevant information on the Full Decision Tree. asks the client about these areas, in case he or she needs to 1. Typing “emphysema” and “treatment” provides links to use less pressure there. Web sites with common treatments for emphysema. 2. A booklet on respiratory disease describes positions that can aggravate breathing problems. The therapist can apply 2. Typing the brand name of a drug or treatment and the the information to positioning and bolstering the client on words “side effect” provides links to Web sites that list com- the massage table. mon side effects of the drug. 3. A brochure on a medication mentions that skin reactions can occur. A therapist, using the brochure, asks the cli- 3. Typing the brand name of a drug followed by “.com”—such ent whether side effects include skin problems and avoids as “Wellbutrin.com” or “Arimidex.com”—brings up the friction, lubricant, and possibly contact on affected areas. manufacturer’s Web site with information about why the drug is prescribed, and common side effects. A simple Internet search for a medical condition or its treatment can yield additional information for patients. For example: 4. Typing in a health condition and “.org”—such as “stroke. org”—often generates a nonprofit association or foundation devoted to research on the condition, patient advocacy, and education.
52 Chapter 4 Interviewing, Decision Making, and Charting A word of caution: Not everything on the Internet is accurate. patients, alike. It is always a good idea to consult several Web However, government Web sites (such as nih.gov), sites run sites to look for consistency, especially about key informa- by hospitals for their patients (such as clevelandclinic.org), tion. Recommended web resources appear in each chapter and large nonprofit associations are often reliable sources of bibliography online. information. As of this writing, excellent, carefully reviewed information about medications is available from the University The Client’s Physician or Nurse of Maryland Medical Center site (umm.edu), at drugs.com, and safemedication.com. Even though advertising is a primary After using the resources listed above, a therapist can usually function of a pharmaceutical Web site, such sources are also design a massage plan, but may still need to fill in gaps in educational. Drug companies share data about their prod- information by consulting with the client’s physician. Chapter ucts in a standard format, useful for health professionals and 5 discusses the steps of physician communication in detail. Presenting the Massage Plan to the Client Once the therapist has arrived at a massage plan for the client’s on, such as your feet and shoulders. Are those areas that presentation, it’s time to tell the client about it and explain the would like attention during the massage? How does this rationale. Some therapists also choose to put it in writing, in an approach sound to you? informed consent process. This explanation has several useful components: ● EXPLAINING MASSAGE CONTRAINDICATIONS 1. A clear description of the massage adjustment, and why there is a need for it. Typically, therapists and clients plan out other elements of the session together, including areas of focus, preferred pressure and 2. Acknowledgement of the client’s past and preferences, and modalities, and so on. Massage adjustments for the client’s medi- how this session might be different. cal conditions are a natural part of this conversation (Figure 4-4). 3. Alluding to general practices in the massage profession—“we When talking to the client about massage contraindications, don’t work too vigorously”—as a foundation for the decision, a therapist may feel self-conscious, as though he or she were rather than the therapist’s personal preference or whim. offering something less to the client. This is most often the case when deeper pressure is contraindicated, or it’s necessary Occasionally, a therapist encounters a client who resists or dis- to avoid a certain area of the body. The therapist may feel the misses the need for the massage adjustment. He or she might weight of a client’s expectations, or pressure from an employer feel that the therapist is too cautious, or that his or her medical to please a customer. Yet, most clients are receptive to mas- condition shouldn’t make a difference in the massage. Perhaps he sage changes, especially when they understand the reasons for or she feels singled out, or misses the “normal” massage he or she them, and feel included in the decision. Here is one way to received before becoming ill or injured. This is more likely to occur explain a contraindication to a new client: in a new therapist-client relationship than in an established one. I understand you prefer very deep pressure, and that’s When a client balks at a massage plan, the therapist may what you’ve liked about massage in the past. Today I’m need to assume more of a leadership role, explaining that he or learning toward gentler pressure on your back, because she needs to abide by the limits for the client’s well-being. This of your osteoporosis. In massage therapy, we don’t work is a different paradigm than “the customer is always right,” and too vigorously on areas that may be unstable. On the it can be challenging to implement in settings that emphasize other hand, there are places I can use a bit more pressure client-centered care and customer satisfaction. It is easier to navigate a client’s resistance when remembering the purpose FIGURE 4-4. Explaining the massage plan. of the contraindication: to do no harm. It can be helpful to tell the client, “I think we should be gentle—the last thing we want is for you to feel worse after the massage. We’d much rather have you feel better!” And it may be that future sessions can be more vigorous, once the client’s massage tolerance is established. (See “the Where You Start Isn’t Always Where You End Up Principle,” Chapter 3.) ● INFORMED CONSENT Some therapists describe the massage plan in a process called informed consent. Informed consent is an educational pro- cess, in which a patient reviews his or her medical treatment plan in writing. It includes the purpose, possible benefits and risks, and the details of the treatment. In medicine, informed consent is vital when invasive procedures are performed, with possible side effects and complications that range from bother- some to life threatening. In the process of informed consent, the patient has a chance to ask questions of the health care provider administering the informed consent form. The patient signs a statement saying
Special Populations and Settings 53 that these steps took place, and that he or she understands and in massage therapy, not even if a client consents to them in accepts the treatment. writing. Unlike informed consent before surgery, informed consent before massage should never be used to justify In massage therapy, informed consent is used to set expec- massage that could cause strong side effects, more serious tations for the session or course of treatment. Some therapists complications, or lasting damage to tissue. use written informed consent, and others use a less formal verbal exchange. Informed consent can be multipurpose: para- A common question for massage therapists arises from meters such as session length, draping practice, clothing to be the following scenario: Suppose a client insists on deep pres- removed, and the areas to be massaged are often included. sure or a strong stretch, even against the therapist’s advice. The therapist describes the need for communication dur- Perhaps the client’s tissues are unstable, or another medical ing the session, and the client’s responsibility to disclose any factor is a concern for the therapist. Is it appropriate for the medical conditions and treatments to the therapist. Informed therapist to offer informed consent, releasing the therapist consent is a chance for the therapist to welcome the client’s from liability if he or she complies with the client’s request? input on areas and pressures, and to underscore the client’s The answer is no. Informed consent is not designed to dismiss choice of how to be touched. The therapist may describe his or a massage contraindication. her scope of practice: that he or she does not diagnose or treat disease, for example. He or she may include general office Here is another way to state this important point: Even if a practices such as the office cancellation policy. client is open to the risk, and willing to state that in writing, the therapist is ethically bound to do no harm. Informed consent Informed consent provides one framework for present- does not release the therapist from liability if injury or illness ing massage contraindications to the client. This is also an occurs, and few practitioners would be comfortable working ideal time to educate a client about possible side effects of unsafely, even with informed consent. Informed consent is massage, such as mild, temporary soreness. These are small for education and communication, not overriding professional risks of massage, common to massage practice. But larger judgment. Any document intended for legal purposes should risks, such as bruising, infection, or fracture, have no place be reviewed by an attorney before use. Charting Massage Contraindications There is a range of record keeping in massage therapy, from Client has mild eczema and both forearms, extensor extensive records, to no written notes at all. Factors that influ- surfaces. Avoided friction and oil on affected areas ence a therapist’s charting include the amount of training in documentation, his or her own personal style, and the facility Figure 4-5A is a visual record of these adjustments for eczema. in which he or she works. Some therapists take formal SOAP notes with standard abbreviations. Others keep informal notes Client has end-stage liver disease with swelling in the on the client’s medical information, his or her progress over abdomen, osteoporosis. Avoided prone position because time, and their own observations during a session. of swelling (used left sidelying). Overall pressure 2 maximum. Avoided general circulatory intent (followed No matter how the therapist documents the session, the Filter and Pump Principle). chart should include massage contraindications that were fol- lowed, with this information: Figure 4-5B is a visual record of some adjustments for liver failure (see “Liver Failure,” Chapter 16; “Osteoporosis,” ● The conditions—illness or injury—requiring the adjust- Chapter 9). ments (from the left side of the Decision Tree). The chart should be kept up to date for a subsequent ses- ● The elements of massage that were adjusted in the session, such sion or course of treatment. Each time, the therapist records as site, joint movement, pressure, intent of the session, and so the client’s response to the previous session, and any changes on (from right side of the Decision Tree—see Chapter 2). in health status. Asking, “Have there been any changes in your symptoms, diagnostic tests, or treatment since I saw Any conversations or correspondence with a client’s physician you last?” and “Have any other health changes occurred or nurse should also be noted, and dated. since the last session, anything new?” can be an effective way to monitor the client over time. A Decision Tree is one format for documenting the massage contraindications that were followed; written notes are another. With a session clearly recorded in the chart, the therapist A pre-made diagram of the human body can supplement these can return to it at subsequent sessions, or reference it when methods, providing an efficient recording format. Therapists seeing another client with a similar clinical picture. A clear mark directly on the diagram with a few notes, a format that record of massage adjustments also provides a form of legal allows simple retrieval of the information. Here are examples of protection for the therapist if his or her liability for injury to a written notes (in longhand, without standard medical abbrevia- client is ever questioned. tions) and supporting diagrams: Special Populations and Settings In the rapidly growing field of massage therapy, interview- the therapist should ask a client, or on how to document ing and documentation methods are still being developed. and apply the answers. Therapists interview differently for Even though there are excellent texts on these subjects different populations of clients, or when working in certain (see Bibliography), there is no universal agreement on what massage settings.
54 Chapter 4 Interviewing, Decision Making, and Charting A. condition, and a diagram of characteristic fibromyalgia tender points to mark, using the client’s self-report of pain or tender- No friction; ness. Another therapist designs a form for pregnant and post- No lubricant partum women; another has a form for people with cancer. (eczema) A therapist specializing in injury work might include ques- B. LIVER FAILURE tions about certain injuries for clients. The follow-up questions Overall pr max = 2 on pain can be an excellent checklist to send out to a client No general circ intent ahead of time, asking him or her to reflect on his or her pain and describe it fully. Therapists who accept third-party reimburse- ASCITES ment for massage therapy, especially as part of injury treat- Pr max = 2 ment, have many resources available to them for interviewing No prone and documentation, listed in the bibliography. No matter what positioning the therapist’s purpose for it is, a specialized form usually saves (used sidelying L) time. Therapists who develop them may be better prepared to serve that population. ADVANCED OSTEOPOROSIS ● CHALLENGES IN DIFFERENT No joint movement at spine, hips. MASSAGE SETTINGS Use gentle pressure (pr max = 1) on paraspinals The massage setting influences interviewing and charting, and there is variation in these practices across the profession. An FIGURE 4-5. A diagram of the contraindications followed in a interview in a hospital inpatient setting might be brief: the massage session is used to supplement handwritten notes. Two patient is fatigued, the massage therapist has already reviewed examples are shown. In (A), the therapist recorded his or her mas- the patient’s medical chart in detail and checked with the nurse sage adjustments at sites of eczema on the client’s forearms. This for key information. The massage session may be recorded in corresponds to the top branch of the Decision Tree for eczema. detail in the patient’s chart. An interview in another clinical (B) The therapist recorded several massage adjustments for a cli- setting might be more extensive, including a thorough history ent with advanced liver failure. and goals for a course of massage treatment, also recorded in a patient’s chart. Standard medical vocabulary and abbreviations ● FORMS FOR SPECIAL POPULATIONS may be necessary in both of these settings, for insurance reim- bursement, or for multiple practitioners seeing the same client. Many therapists specialize in certain kinds of work, such as prenatal massage, geriatric massage, or massage with athletes. An interview in private practice may reflect a therapist’s One way to streamline the interview process is to include specialty, or be broad based, and the therapist’s notes may be commonly used follow-up questions on a single form, perhaps highly individualized. In high volume massage settings, such aimed at specific medical populations. For instance, working as spas, resorts, and cruise ships, the interview may be con- with several people with fibromyalgia, a therapist discov- strained by a short turnaround time between clients. In these ers a simple way to ask some common questions. He or she cases, the interview might be extremely brief, amounting to a develops a quick fibromyalgia checklist for any client with this question or two, or a more fully developed checklist of medi- cal conditions. In on-site or “chair massage” settings, located in shopping malls, airports, and special events, there is usually no chart- ing. Contraindications may be managed by a quick sign-in or release form, asking the client to review a quick checklist of conditions or symptoms and verify, by signature, that he or she is not experiencing any of them. While interviewing and charting would offer some protection against liability in such settings, it would also lengthen each exchange and diminish the possible volume. Conventional practice in these and other massage settings is likely to evolve as the field of massage therapy continues to develop. ● INTERVIEWING FOR CONTRAINDICATIONS IN THE SPA Although many therapists are employed by spas, the spa setting can provide challenges in the areas of interviewing, documentation, and massage contraindications. In some spas, a full medical intake is performed by a nurse or another pro- fessional, upon entrance to the spa, who designs the guest’s spa services with his or her health history in mind. However, in most spas, little or no health information is solicited, and no records are kept.
Special Populations and Settings 55 BOX 4-4 THE SPA HEALTH CHECKLIST 1. Do you have any medical conditions? Have you been recently or currently treated for any medical condition? Ask the follow-up questions for any condition. 2. Any recent or scheduled medical procedures? Follow the Procedure Principle, and ask the follow-up questions about diagnostic tests (this chapter) to determine whether there is a medical condition to consider. The Procedure Principle. Adapt massage to the condition for which the procedure is advised, and to the effects of the procedure itself. 3. Are you taking any prescription or over-the-counter medications? Ask the four medication questions. 4. Do you have any condition that affects your bones, joints, or muscles? Keep the Unstable Tissue Principle in mind, as well as the pain, injury, and inflammation principles. The Previous Massage Principle can be extremely useful here. 5. Any conditions that affect your skin? If there are, some of the follow-up questions about infection should be asked to determine communicability. Be familiar with the skin principles in Chapter 7. For most skin conditions, the Exfoliation Principle (see Chapter 3) should be applied, at least at the site. 6. Any conditions affecting your nervous system, heart, lungs, liver, or kidney? Ask about whether the condition affects the function of the organ. If it does, apply the Vital Organ Principle; also apply the principles concerning spa treatments—the Detoxification Principle, the Exfoliation Principle, and the Core Temperature Principle. 7. Is there any cancer or cancer treatment in your health history? Any removal or irradiation of lymph nodes, if so? Even if the cancer was a long time ago, some treatments have lingering effects. Depending on the case, the Quadrant Principle for Lymphedema Risk could be important to apply, and additional follow-up questions about cancer history are essential for working safely (see Chapter 20). 8. Are there any surgeries in your health history? Use the Procedure Principle. If the surgery was recent, follow the Unstable Tissue Principle or the Stabilization of An Acute Condition Principle, as needed. Review “Surgery,” Chapter 21. 9. Any pain or discomfort anywhere? Where and from what? Principles concerning pain, injury and inflammation should be considered here. Yet massage therapists in these settings encounter a Tree, or look up specific information, a therapist may rely broad range of client presentations: serious illness and more heavily on broad massage principles. Principles intro- injury, chronic and progressive conditions. Therapists seeing duced in Chapter 3, and additional principles in Parts II and clients in these high-volume settings, with many first-time III, are easy to use quickly, and can be invaluable to spa staff. clients, may be scheduled so tightly that there’s no time for Therapists in such settings should always be mindful of the an extensive interview. In such settings, therapists are often Massage Setting/Continuity of Care Principle. confined to the single question: Is there anything that I should know about your health? The Massage Setting/Continuity of Care Principle. In massage settings favoring single-time rather than repeat clients, lacking There is a problem with this approach, putting the burden continuity of care, or using little or no documentation, therapists on the client to know and understand which health informa- should take a cautious approach to medical conditions. tion is relevant to massage. Only the therapist can determine whether a client can safely receive massage and spa services, A therapist who grows comfortable with interviewing, and it is up to the therapist to ask the right questions. A decision making, and charting is richly rewarded in his or her brief spa health checklist, condensed from the longer cli- work. Able to work confidently with a range of ages, illnesses, ent health form, can get therapists started at obtaining the injuries, and levels of health, a skilled therapist draws clients essential information from their clients (Box 4-4). To make quick decisions with one-time clients, without the time to explore each condition fully, complete a Decision
56 Chapter 4 Interviewing, Decision Making, and Charting with complex presentations to his or her practice. Through during a massage session, that client’s story continues to be exchanges with some of the most challenging experiences of told through touch. Depending on many factors, the conver- the human condition—those that affect the human body—the sation could last for the next hour or for a decade. However therapist may deepen her experience of her clients and the long it lasts, the therapist’s notes chronicle the ongoing work of skilled touch. exchange of information, the client’s response to massage, and the massage provided. Listening with his or her ears, Each person’s body tells its own unique story of health and hands, and heart, the therapist attends to the client’s story as healing, illness and injury, tension and movement. Questions it continues to unfold. start the conversation between a therapist and client, and SELF TEST 1. How could you find out, online, the common side effects 6. There are four questions to ask about each of a client’s of a medication a client is taking? medications. State the four questions and their purpose. 2. Why is it important to use a layered approach to interview- 7. If a client has an illness or injury, then what questions ing, asking for some of the same information in several should you ask about his or her activity and energy level? ways? How the client’s answers influence the specifics of the massage plan? 3. What are three follow-up questions to ask about a medical condition, in order to complete a Decision Tree for that 8. List three guidelines for locating reliable medical condition? information on the Internet. 4. If you discover in the interview that a client’s pain or injury 9. List three things a therapist can do when he or she is accompanied by muscle weakness, what do you advise? suspects that a client is giving incomplete or inaccurate health information during an interview. 5. Regarding a client scheduled for a diagnostic procedure, what questions do you ask, and which principle do you 10.Why is it essential to ask a recently injured client about apply to design the massage plan? State the principle in your any insurance claim or litigation involving the injury? answer. For answers to these questions and to see a bibliography for this chapter, visit http://thePoint. lww.com/Walton.
Chapter The Pitfalls of the Simple “Doctor’s Note” 5 Communicating with the Client’s Physician A dialogue is more than two monologues. is changing, the lack of an organized connection to conventional health care has made it challenging, at times, —MAX KAMPELMAN for therapists and physicians to join in partnership in patient care. Many massage therapists, unaccustomed to medi- In some cases, the client’s health status requires outside cal language and practices, are uneasy about approaching advice on massage contraindications, and the massage conventional health care professionals for dialogue about therapist needs input from the client’s physician or other the interactions of medical conditions and treatments with health care providers. On the Decision Tree, the shorthand massage therapy. When an opportunity for conversation for this action is medical consultation. A physician may does occur, it may be complicated by ambiguity about the be consulted, but depending on the context, the provider benefits and contraindications of massage. might be one of the physician’s representatives, such as a nurse practitioner (NP), nurse, or physician assistant (PA). Without a formal infrastructure for dialogue, therapists For simplicity, this book uses “physician consultation” and have been advised to simply request a permission note “medical consultation” as collective terms that mean com- from a client’s physician, approving massage therapy for the municating with any of these providers about a client’s mas- patient with a medical condition. In this chapter, the limita- sage plan. Several communication samples are introduced tions of this approach are discussed, along with alternative in this chapter. For some client presentations, a physician methods of communication. Guidelines for consulting with consultation can play an important role in massage therapy. a physician collaboratively are introduced, together with a clear picture of what is needed from the physician in order In many countries, there is no defined relationship for the massage plan to go forward. between massage therapy and medicine. Although this The Pitfalls of the Simple “Doctor’s Note” In the massage field, lists of massage contraindications have In medicine, there is no established line of thinking to often included the need for a physician’s permission for mas- approve a patient for massage therapy. Compare this to sage, and many therapists are trained to ask for such a note other, more familiar activities: A physician gives permis- when there is any question about the safety of massage. Often sion for a patient to drive 6 weeks after surgery or to this note is requested of the client, who, in turn, requests it begin to operate machinery after successful treatment for from his or her physician. Unfortunately, this form of com- a seizure disorder. A physician may prescribe supervised munication is usually too brief and one-dimensional to be exercise at a certain point after a heart attack or give meaningful. Its usefulness is limited, for several reasons: permission for a patient to participate in school sports. These are familiar activities with predictable effects on 1. In asking for permission for any massage rather than the body. The interplay of massage therapy and medical input on specific massage elements, the therapist’s conditions is less clear, without established guidelines or request is too general. practices. 2. The physician may not be well informed about massage In the absence of such guidelines, the massage therapist therapy, or about the specific therapist’s work. takes on more of a leadership role in physician communica- tion, encouraging the flow of information in both directions. 3. With little information available in the literature about The therapist asks questions about the client’s condition the effects of massage, the physician may not have con- and the advisability of certain massage elements and raises sidered how massage elements interact with the patient’s the physician’s awareness about massage contraindications. medical condition and cannot effectively address the The physician offers needed medical information and a therapist’s question. medical perspective on the massage plan. The physician and the massage therapist put their heads together for the 4. Deference to the client’s physician in these decisions welfare of the client. sidesteps the therapist’s professional responsibility for investigating massage contraindications on his or her own. 57
58 Chapter 5 Communicating with the Client’s Physician Roles and Responsibilities Clear roles and responsibilities can pave the way for good ● COMMUNICATION STEPS communication. If the therapist is clear about what he or she needs, the steps to take, and what he or she expects of the phy- A consultation with a client’s physician involves four steps: sician, it increases the likelihood of a productive exchange. 1. Communication: Establishing a method of communica- ● THE MASSAGE THERAPIST’S tion between the therapist and the physician. RESPONSIBILITIES 2. Education: Informing the physician of the practice of A physician consultation involves planning and preparation. adapting massage therapy to medical conditions, the Before initiating communication with the physician, the specific concerns about the client’s condition, and the therapist does the following: proposed massage adjustments for the client. 1. Gathers as much information as possible about the cli- 3. Input: Requesting information from the physician about ent’s health in the client interview; the client’s medical condition and potential interactions with massage. 2. Educates herself or himself about the client’s condi- tion, using medical literature and patient education 4. Approval: Obtaining the physician’s permission to pro- resources; ceed with the massage plan (in certain cases). 3. Searches the massage literature, including this text, for By initiating contact and establishing lines of communication massage therapy guidelines for the condition; with the client’s physician, the therapist can then raise the physician’s awareness about massage contraindications and the 4. Answers as many questions as possible for herself or adjustments that might be in force for a particular client. This himself, perhaps by sketching one or more Decision paves the way for the physician’s acknowledgment of the Trees, reviewing massage principles, or asking the cli- massage plan, input into it, or permission for it to go forward. ent a few more questions (see Chapters 1–4); In steps 3 and 4 mentioned above, the distinction between 5. Identifies any unanswered questions, focusing them on information from the physician and physician permission or specific medical information that has bearing on the approval is an important one. If permission is necessary, it massage plan; usually satisfies requirements of a facility serving a medically vulnerable population, or even a licensing law. Asking for infor- 6. Prepares questions for the physician. mation is another thing altogether—it is a request for dialogue. The therapist is not expected to have a vast store of medical ● THE PHYSICIAN’S RESPONSIBILITIES knowledge about the client’s condition. However, by carry- ing out the first four tasks mentioned above, the therapist By engaging the physician in a discussion about a client, the might answer his or her own questions, making physician therapist is asking the physician to: communication unnecessary. This is especially true as the therapist grows in experience. ● Consider the therapist’s questions about the patient’s medical condition; The Clinical Judgment Improves with Experience Principle. An experienced therapist can more safely and ● Give weight to the therapist’s concerns about the inter- readily predict a therapeutic outcome or anticipate a actions of massage and the condition; problem than a beginning therapist. ● Answer the therapist’s questions with any information, If the therapist does identify unanswered questions, she insights, and medical perspective that are needed for the makes them as clear as possible and is then ready to consult massage plan. the physician. At this point, her responsibility is to facilitate the consultation, guiding it as well as possible to a produc- It is not part of the physician’s role to teach the therapist all tive exchange. about the client’s medical condition. Nor should the physician be expected to substitute for a good intake interview—it is not the physician’s responsibility to supply information that the therapist could reliably get from the client. Finally, it is not up to the physician to shoulder the responsibility for the safety of the massage; that responsibility is the therapist’s. Consulting a Physician One of the therapist’s primary responsibilities in consulting a ● THE CLIENT’S AUTHORIZATION physician is to define specific questions. Having phrased these questions as clearly as possible, the therapist determines the A client’s authorization to release medical information is best health care provider to approach. But before the thera- required for any direct correspondence between his massage pist communicates directly with that person, he or she obtains therapist and his physician’s office. By its nature, any corre- the client’s written authorization for the communication. spondence between the therapist and the physician involves
Consulting a Physician 59 Authorization to Release Medical Information Client Name: Date of Birth: Address: City, State/Province: Telephone Number Contact Person (if other than client): Phone: I: authorize Shawn MacKinnon to disclose my health care information to the following health care provider: Name: Address: The following information may be disclosed (check all that apply): All health care information in my medical chart. Only health care information relating to the following injury, illness, or treatment: Only health care information for the following dates or time periods: Including information regarding HIV, sexually transmitted disease, mental health, drug or alcohol abuse. I give my authorization to release health care information for the following purposes (check all that apply): To share information with my health care team in an attempt to coordinate care To obtain payment of care expenses I have incurred for my treatments To take part in research Other: This authorization expires on: (no longer than 90 days from the date signed) Date: Event: I understand that I may refuse to sign this authorization. I may also revoke this authorization at any time by writing a letter to Shawn McKinnon Massage Therapy. I understand that once my health care information is disclosed there is the potential for unauthorized re-disclosure and it may no longer be protected by HIPAA or state privacy laws. Shawn MacKinnon Massage Therapy will continue to maintain the confidentiality of patients’ medical records mandated by the Federal HIPAA Privacy Rule. I also understand my obtaining care cannot be conditioned on my signing this release. Date Signature FIGURE 5-1. Sample authorization to release medical information. (Adapted from Thompson D. Hands Heal, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006.) exchanging private information about the client’s health. In laws complicate matters. But no matter where the massage the United States, this is called protected health informa- therapist practices, client confidentiality is one tenet of tion (PHI). PHI includes information documented in the professional ethics and the therapist-client relationship. client’s medical records and massage records. Even the fact This confidence can be broken only by written permission that he or she is receiving massage therapy is PHI, and other from the client. In the United States, regulations govern- data—the client’s date of birth, address, other identifying ing the protection and handling of PHI are contained in information, and any medical conditions—are likewise private the Health Insurance Portability and Accountability and protected. A client’s written, signed, and dated authori- Act (HIPAA) Privacy Rules of 1996. HIPAA resources zation, on file in both the massage therapist’s office and the for massage therapists are listed in the bibliography at physician’s office, is necessary in order for a therapist and a http://thePoint.lww.com/Walton. physician to discuss this information. A sample client authori- zation to release medical information is in Figure 5-1. ● QUESTIONS TO ASK Different countries have different laws about confidential The questions in a medical consultation should be thought- health information, and even different states or provincial ful and focused—the question, “Is it okay for this person
60 Chapter 5 Communicating with the Client’s Physician TABLE 5-1. SAMPLE PHRASING OF QUESTIONS FOR A CLIENT’S PHYSICIAN Medical Condition Possible Massage Adjustment Question to Physician Scabies General contact I need to know if this patient’s skin condition, scabies, has resolved and is no longer communicable before I can provide any touch therapy. Can Osteoporosis Joint movement, pressure I offer her massage and touch on my table, without any risk to myself or other clients? Spinal Cord Injury Overall pressure, varying posi- I am aware of this client’s osteoporosis. She prefers deep massage tions, joint movements pressure, but it is unclear, from my interview with her, how stable her spine is, so I have not provided deep pressure. In my practice, I use stretching, range of motion, and five levels of massage pressure (attach pressure scale). In my opinion, medium pressure—a maximum pressure of 3 on her paraspinal muscles—and only gentle movement at her hip and shoulder joints are appropriate, but we need your input on the safety of this. Are you concerned about this pressure or about any other activities for this patient? What is her risk of pathologic fracture from this kind of intervention? This client recently sustained a spinal cord injury. Since it has been only a few weeks since the accident, I want to ask you about autonomic dysreflexia (see “Spinal Cord Injury,” Chapter 10). Is his blood pressure stable enough for him to receive massage of his upper body, with vari- ous pressures, positions, and joint movements? Is there anything I need to be concerned about or certain signs of dysreflexia that I should be alert for? to receive massage?” is too general. Instead, the therapist Consulting the Nurse includes specific elements of massage in the question. Perhaps the client has a sign or symptom that seems to In most situations, the massage therapist ends up commu- contraindicate deeper pressure levels or the movement of nicating with the physician through the physician’s nurse, joints in a certain area. Or maybe the therapist needs to which is ideal. Often, the nurse is the front line of commu- know whether contact is safe, if an infection has resolved. nication from the physician’s office, fielding questions and These are reasonable questions to ask of a client’s physician requests from the client and client’s family, and is “the way or physician’s representative. Examples of questions and in” to communicating with the physician. The physician’s phrasing are in Table 5-1. nurse may be more available by phone and often commu- nicates with other practitioners. She or he may help process ● APPROACHING VARIOUS paperwork, such as a care plan or form sent by the thera- pist, and is a natural intermediary. Communication with the PRACTITIONERS nurse has several advantages: A therapist seeking a medical consultation may also need 1. Training in massage. Massage as a comfort measure has to determine which practitioner to consult. Some people traditionally been part of nursing training; nurses tend see several different physicians for a single condition, or to understand the dynamics of massage and appreciate for multiple conditions. This could include a primary care its benefits and contraindications. practitioner (PCP), an orthopedist, a cardiologist, or an oncologist. Many physicians’ offices also include a PA or 2. The benefits of touch. Nurses have often championed NP, both of whom are licensed to diagnose, treat, and man- massage therapy for patients, and much of the research on age disease. With the authority to prescribe medications massage therapy appears in nursing journals. Many nurses and order tests, these providers can also be consulted for go on to study touch and energy modalities in an effort to advice, acknowledgment, or approval of a massage plan. bring touch and massage back into nursing care. For a question about a condition or treatment, consult 3. Handling the body. In normal nursing care, nurses handle the treating physician or physician’s representative. If a the body more often, and for longer periods than most client has multiple conditions or treatments, the best per- physicians—applying lotion, supporting and repositioning son to contact is usually the physician or representative who patients, and checking for vital signs. They can readily sees the client regularly, often the client’s PCP. Although consider equivalent modifications in contact, lubricant, the PCP might not be treating the condition in question, pressure, movement, and positioning in massage therapy. he or she still has an understanding of how multiple treat- ments can affect the different body systems. The client usu- Formal physician approval for massage must come from the ally has the easiest access to that person and has established client’s physician, physician’s assistant, or NP, and each time a rapport and an ongoing relationship. medical consultation appears on a Decision Tree, it signals com- munication with one of these providers. But input from nurses
Communication Methods 61 is vital to most massage conversations. The nurse is a valuable More and more physicians and other health care providers resource, not just as an intermediary, but because she or he are becoming familiar with massage and touch therapies and can provide useful insights and direction for massage therapy. welcoming these for their patients. Communication Methods There are several ways to initiate communication with they do not make a copy, the therapist has a convenient, a physician whom the therapist has not worked with or complete record of the correspondence on one or two met: pages. 1. Direct communication, using a personal letter ● STREAMLINING COMMUNICATION: 2. Direct communication, using a pre-made format, such THE MASSAGE THERAPY as a massage therapy care plan 3. Indirect communication through the client, by asking CARE PLAN the client to bring a question to his or her physician Generating a personalized letter to every client’s physi- cian, for every question that comes up, can become Direct contact with a physician is usually most effective tedious. A therapist can save time by developing massage when it is in writing, giving him or her a chance to read protocols for common situations or for a population of and respond on his or her own schedule. By writing, the the therapist’s specialty. Among other things, a protocol therapist has time to formulate questions and collect describes the massage approach, expected outcomes or thoughts and to make it as professional as possible. Written benefits, and massage contraindications. A protocol can correspondence documents the communication between be set down in a format called a massage therapy care the massage therapist and the physician. Where necessary, plan. The term massage plan is an informal term used a telephone call can follow the written contact. throughout this book, usually to describe massage con- traindications for an individual session. The term care ● THE PERSONAL LETTER plan has a broader meaning in the context of medical care. In medicine and nursing, a care plan is not only In a personal letter, the therapist draws on information in for contraindications; it also describes a course of treat- Chapter 2 to describe massage therapy in plain, universal ment, expected treatment outcomes, ways to measure terms, using the elements of massage and avoiding trade them, and a timeline for the course of treatment. A mas- names and modality names. The therapist includes relevant sage therapy care plan includes all of these elements factors in the client’s condition and specific concerns for the adapted to massage therapy. physician to address. It is not necessary to restate massage principles, include Decision Trees, or attach the completed Typically, care plans in medicine are informed by client health form, as these are tools for clinical decision clinical research about which therapies are effective. making rather than finished correspondence. Instead, the In massage therapy, there is not yet a sufficient body of therapist introduces a provisional massage plan and asks the research to support one massage approach over another physician for one or more of the following: for a certain client presentation (see Chapter 6). Until research is available, care plans in massage therapy are ● Health information to fill in any gaps based on therapists’ clinical observations, case reports in ● Input on massage contraindications professional literature, and the advice of instructors and ● Approval for the patient to receive massage colleagues. A written inquiry to the physician should be brief—no more Figure 5-3 is a basic massage therapy care plan for a cli- than one or two pages. The note should be well organized ent in cancer treatment and a request for the physician to and contain clear information. The questions should be as review the plan, acknowledge it, and comment on the plan specific as possible. Figure 5-2 is a sample of a personal let- if he or she feels it is necessary. The care plan is somewhat ter to the physician with specific questions about a massage generic, in that it includes common massage issues for this plan. population (see Chapter 20). The therapist left some of the general information in the plan but customized much In the letter, outline exactly what is needed from the of it to his or her individual client before sending it to the physician and a clear, easy, and useful way for the physi- physician, along with a short note. Similar forms are used cian to respond. Most physicians’ offices have a staggering by many oncology massage therapists in the United States volume of paperwork. A request from a massage therapist (MacDonald, 2007). can be a daunting additional task to complete. One way to smooth the feedback process is for the therapist to ask In this example, the care plan is not designed to start the physician to complete a form enclosed with the letter, a lengthy dialogue about a specific question; instead, or even within it, then sign it and return it to the therapist the therapist asks for acknowledgment of the care plan (see Figure 5-2). and invites comment. However, depending on the Presumably the physician’s office will copy or record (text continues on page 64) these communications for their patient record, but even if
62 Chapter 5 Communicating with the Client’s Physician Date Dr. Frances Lin Valley Medical Associates 123 Pleasant Street Prospect Valley, PA 19320 Dear Dr. Lin: Your patient, Mr. Gene Werner, DOB 5/12/58, has given me permission to contact you. Mr. Werner would like to receive regular massage therapy in this office. I am writing to ask your input on massage therapy and movement for him, and approval for going forward with our massage plan. Because this patient sustained whiplash injuries in a motor vehicle accident 10 weeks ago, I would be grateful for your input. Provisional Massage Therapy Plan Overall, the massage session would include kneading, stroking, and stationary pressure, using gentle to medium, “warming up” pressure on the muscles of the back, shoulders, hips, arms and hands. No deep pressure would be used at the occiput, neck, or shoulders. I am asking for your recommendations, for or against the following: Massage of the neck muscles, lateral and posterior, with gentle to medium pressure, engaging the medium layers of muscles, pressure slightly more than that needed to “rub in” lotion or sunscreen. Medium, focused fingertip pressure to the attachments at the occiput, including the SCM attachments at the mastoid. Gentle movement of the neck, perhaps passive rotation up to 30 degrees right and left, and passive side flexion to 40 degrees right and left, to patient’s tolerance. In your best estimation, can these techniques be done safely at this point, without aggravating the patient’s discomfort or injury, or interfering with medical treatment? Is this plan appropriate? Please comment below on this provisional plan and return it to my office at the above address. Also, please feel free to call with questions or concerns. Thank you for your consideration. Kind regards, Joanne Lightfoot Physician Recommendations for Massage Therapy Plan I have reviewed the above massage plan for my patient, Mr. Gene Werner, and circled yes, below, next to techniques I recommend, and no, below, next to techniques I do not advise: (Please circle yes or no in each case) Yes No Direct massage of neck muscles, lateral and posterior, with gentle to moderate pressure. Yes No Focused fingertip pressure at moderate pressure to attachments at the occiput, including the mastoid process. Yes No Gentle passive rotation of neck to 30 degrees, right and left Yes No Gentle passive lateral flexion of neck to 40 degrees, right and left I have noted any additional exclusions or recommendations below: Physician’s Signature Date Print Physician’s Name FIGURE 5-2. Sample personal letter for physician consultation.
Communication Methods 63 Deval Montgomery, MD Oncology Associates of Amarillo 24 Curtis Ave. Amarillo, TX 79118 Dear Dr. Montgomery: Your patient, Earlene Sikes, DOB 1/19/49, would like to receive massage therapy during the course of her cancer treatment. I’m enclosing the massage therapy care plan for your review, and welcome your input. The care plan lists common massage adaptations for patients in cancer treatment, and I have circled those that are relevant for this patient. Please return a signed copy of the care plan in the enclosed envelope, and feel free to call me at the number above if you have questions or concerns. Thank you for your time and consideration. Warm regards, Paula Santos, LMT Massage Therapy Care Plan Client is in treatment for breast cancer: Left lumpectomy and axillary lymph node dissection December 2009, chemotherapy planned through March 2010, to be followed by a six week course of radiation therapy. Client complains of nausea, fatigue, muscle pain in neck and shoulders, and sleep disruption. Goals of Massage Therapy Treatment (Outcomes Assessed at Each Treatment) Improvement in client self reports of overall relaxation Improvement in self reports of sleep quality and duration Muscle relaxation, as measured by palpation, observation of posture, client self reports of pain and stiffness Reduction of complaints of nausea, as reported through verbal analogue scale (0-10) Course of Massage Therapy Treatment One-hour relaxation massage sessions, 1X/week, until completion of cancer treatment Course of Massage Therapy Treatment General relaxation massage with focus on areas of muscle pain Kneading, stroking, and compressions to the tissues Gentle passive stretching and range of motion Range of massage pressures, from movement of the skin (as in applying lotion, or “lotioning”) to compression of medium layers of muscle. Common Massage Therapy Adaptations for Clients in Cancer Treatment (Relevant conditions are circled): Sites affected by surgery, radiation therapy, skin conditions, pain, edema, or bone involvement Avoid deep pressure and in some cases medium pressure and even contact on affected areas. Areas at risk of lymphedema If there is any removal or radiation of lymph nodes with lymphedema risk, use only “lotioning” pressure on the extremity and on the associated trunk quadrant. If needed, the limb is elevated during the massage. Unstable tissues due to malignancy, easy bruising, bone metastasis Gentle overall pressure or gentler pressure at specific sites, as needed. Side-effects of cancer treatments Limit pressure depending on symptoms and massage tolerance (begin with (“lotioning”), use slow speeds, even rhythms, and limited joint movement, to avoid aggravating symptoms (nausea, pain, fatigue, poor sleep): Possible increased risk of DVT, secondary to malignancy, cancer treatment, or other factors Limit joint movement, avoid use of medium or deep pressure on lower extremities if risk of thrombosis exists. Physician Acknowledgement of Massage Therapy Care Plan I have reviewed the above massage therapy care plan for my patient, Ms. Earlene Sikes, and noted the massage adjustments circled. If I suggest any additional massage adjustments, have any other information, or have any concerns about the appropriateness of the above plan for this patient, these are described below: Physician’s Signature Date Print Physician’s Name FIGURE 5-3. Sample massage therapy care plan.
64 Chapter 5 Communicating with the Client’s Physician therapist’s intent, she can word her correspondence differ- jots down his or her questions for the physician to help the ently. She may: client remember them. ● Request the physician’s formal approval of the care plan This through-the-client method of communication has by adding a statement of permission or approval for the advantages. It is generally quicker and takes less effort physician to sign. than working up a written communication to the physi- cian. Because the client controls the flow of information, ● Request specific information by adding a question to the it does not require an additional written release of medical correspondence and a means for the physician to answer information. It also empowers clients in the dialogue about it easily. their health and the potential for it to interact with mas- sage therapy. The approach may work well in high-volume Because care plans collect the typical massage therapy massage settings with little or no record keeping, where issues and approaches in one place, they are worth devel- the client sees the same therapist regularly and there is no oping for common, medically complex conditions such as infrastructure for written communication, but questions heart disease, diabetes, cancer, or HIV/AIDS. A prepared arise over a course of treatment. massage therapy care plan has four obvious benefits: This communication method has disadvantages, too. 1. In the process of preparing the care plan, the therapist For it to be meaningful, the therapist has to trust the client familiarizes himself or herself with the common mas- to clearly convey the concern to the physician and then to sage adjustments for a particular medical condition. accurately return the physician’s response. The information This is a valuable learning experience. might be too complicated for the client to describe to the phy- sician, and he or she might not be able to answer the physi- 2. By targeting specific outcomes of a session or a course cian’s follow-up questions. Therefore, to use this method, the of treatment, the therapist attends to massage benefits therapist needs to be confident that the client understands as well as contraindications. the concern, shares it, and can be a reliable intermediary. In “Reliable Communication Is Key,” a therapist describes a 3. By using the care plan format, the therapist enhances scenario in which it would be unwise to go through the client the professionalism of his or her work. to communicate with the physician (see online). 4. The care plan serves as a template, ready to modify for Another disadvantage of communicating through the a client presenting with that condition. This saves time client is the lack of a formal paper trail. Without a written later, smoothing the way for good communication with record of the exchange, the therapist cannot reference it the next client’s physician. over time but must rely on his or her own memory and the client’s memory of what the physician said. The lack of By requesting the physician’s signature, the therapist links documentation also leaves the therapist professionally vul- the education of the physician to an acknowledgment, nerable if something goes wrong, and a complaint is made input, or approval mechanism. If the therapist needs a cer- against the therapist. tain question answered, he or she can put it in the accom- panying note or put the care plan into a yes/no format, If the information can be reliably conveyed through a similar to the personal letter in Figure 5-2. client intermediary, it may be the fastest, most meaning- ful way to communicate. But occasional communication The care plan eases the communication process for both through a client is not appropriate for a complicated ques- the physician and the therapist. It may introduce a pause tion or for a serious condition, where real injury could result. into the blizzard of the physician’s paperwork, a moment to Typically, a written exchange provides a more thorough consider the therapeutic benefit of massage and the impor- route, one that is safer for everyone. tance of contraindications. Although the primary purpose of such a form is communication, it can also draw attention ● FOLLOWING UP to the therapist’s work. In “Raising Awareness with Paper- work,” a massage therapist describes several examples of As the client’s health changes, the documentation should this (see online at http://thePoint.lww.com/Walton). likewise be kept up to date. Whether this requires periodic physician consultation is another question. There is no ● COMMUNICATING THROUGH set rule for how often to contact the physician about an THE CLIENT ongoing health issue; it is an individual decision, based on massage issues that arise. If changes in a client’s health sta- Although direct, written communication is advised for tus lead the therapist to specific questions or concerns, an a medical consultation, some therapists find occasion to updated medical consultation is probably necessary. communicate with the physician through the client. This method can be simpler, although sometimes it is more com- Advantages of regular correspondence with a physician plicated than direct communication. The therapist may ask include the opportunity to remind him or her of the benefit the client, for instance, “Please ask your doctor about this that the client is receiving from massage and continued skin rash you told me about, and find out if she’s sure it’s not prompting about the role that massage therapy plays in communicable before we schedule an appointment.” Or, the client’s life. These reminders may strengthen the pro- “Ask your doctor if it’s okay for you to stretch at that joint, fessional relationship and build bridges between massage and for me to give you what we call ‘a passive stretch.’ Or therapy and medicine. does she think we should wait?” If needed, the therapist
Problem Solving 65 Problem Solving Consulting with a client’s physician often goes smoothly, Any verbal exchange must be documented: The therapist including all the desired steps. However, problems some- records the name and position of the physician or nurse, times occur, such as the following: the date and time of the conversation, and all relevant and specific information exchanged. ● There is no response from the physician to the thera- pist’s inquiry. ● INCOMPLETE RESPONSES ● The physician’s response seems incomplete—he or she Sometimes it might appear that the physician responded to seems to have approved the massage plan without con- a massage question too hastily, signing a form without con- sidering all of the issues. sidering all the issues. In this case, the physician’s acknowl- edgment, input, or approval of the plan was obtained, but ● Conflicting opinions arise between the physician and it is not clear whether communication and education took the therapist or between two other health care providers place. The physician’s response may be empty without regarding massage therapy and the client’s condition. these steps. There are a couple of ways to address incom- plete responses. One is to persist, in writing, by phone, or These scenarios are discussed below, along with some through the client. Another is to follow it up with a yes/no possible strategies. Whatever exchange ends up occurring format described below. between the therapist, physician, and client, the therapist should ask himself or herself afterward: Do I have the If the therapist decides to pursue an expanded response answer to my question? Am I convinced that the massage from the physician, by phone or letter, it is important to be plan is safe? If the answer is yes, the massage plan can pro- polite, understanding, and specific. For example: ceed. If not, there is more work to do. Thank you for responding to the massage therapy ● HANDLING NONRESPONSE care plan I sent you. On the form, I noticed that you approved general pressure, but I don’t see any Even after a therapist sends a well-written form, or the mention of pressure on this specific area, given the most personalized letter, some physicians’ offices may not patient’s vascular condition. Because of the condi- respond. Reasons for nonresponse vary. The office might tion, I need to know your thoughts about pressure be backed up on processing paperwork. A key person there. I hope we can talk more about that, since the involved in processing paperwork could be out of the office client is asking for specific pressure on that area. due to illness. The physician may have seen the form but We’ll be able to proceed with the massage once you set it aside, wanting to give it more attention later. Because give us your opinion. Thank you for making time to a variety of factors can interfere with the timely processing respond. of a therapist’s correspondence, it is important not to take it personally if there are delays. Occasionally, the therapist may need to be even more direct and focused in an inquiry, especially in questions about Unless a facility or regulation requires physician approval massage pressure and unstable tissue. Being explicit about for massage, a communication delay does not typically hold pressure may help, as in the following example: up massage therapy entirely; more likely, it postpones a specific massage plan. The therapist leaves out the massage If appropriate, I could lean in and use a fair amount elements in question but can begin cautious work with a of pressure in this area. Generally at my medium and new client or continue with a current client, until the physi- deep pressure levels, joints move. At the deepest pres- cian consultation is complete. sures, the deep muscles and vessels are compressed and I engage the underlying bone. I am concerned If delays are prolonged, it is primarily the client’s respon- about the stability of the tissues in the area. Would sibility, rather than the massage therapist’s, to engage the you recommend this level of pressure, or should I physician (or, if a client is unable to advocate for herself hold back? Can you tell me which factors you con- or himself, it is her or his family’s or health care proxy’s sider in your recommendation? responsibility). If the physician does not respond to the therapist’s request for communication, the client is in the Depending on the therapist’s tone, these statements could best position to facilitate an exchange. sound terse or challenging. Maintaining a friendly, recep- tive tone, while remaining professional, is the key to getting One reason for nonresponse might be the physician’s the best possible response. concern about being liable if something goes wrong during massage, or a concern that massage will harm the client. In The Yes/No Format these situations, more communication is needed, not judg- ment or snap decisions. Perhaps another way to communi- When a form for the physician is returned with no detail cate can be worked out; a physician who is reluctant to sign on it, it is hard to know whether the physician was able to a form might prefer phone conversation. Ideally, the corre- take a good look at it before signing. Another way for the spondence should be in writing, but if the physician’s input comes over the phone, there is still a chance for dialogue.
66 Chapter 5 Communicating with the Client’s Physician therapist to get specific questions addressed is to use a yes/ course is advised. The client, of course, has the right to no format. The physician simply circles the answer and refuse a technique or massage element, no matter how signs the form. See Figure 5-2 for a yes/no format, in this much benefit or how little harm it might hold. The physi- case, as part of a personal letter to the physician. cian has the right to withhold approval, if concerned about the plan. And the massage therapist has the right to omit An inquiry to the physician in a yes/no format can be in massage elements that he or she thinks are potentially a letter, a care plan, or any other checklist. The questions harmful, even if the other parties are in favor of it. need to be focused, and the therapist should avoid asking the physician to recreate the client health form by asking The Shred of Doubt Principle. If there is a shred of doubt questions that are better directed to the client. For instance, about whether a massage element is safe, it is contraindi- asking the physician about each symptom or sign of a client’s cated until its safety is established. When in doubt, don’t. condition, such as nausea or headache, can be a waste of time, and symptoms can change frequently. Yes/no questions can be In the client-therapist-physician triad, if conflicting presented to the physician in the form of statements, such as: opinions result in strong disagreement or dispute, the best response is more communication and education. Become ● Because of this patient’s medications, he is susceptible to curious about the opposing view, and be inquisitive. Try bruising and bleeding. more communication, written or verbal. Consult resources in the literature. Work with, rather than against, the other ● This patient’s blood pressure is well controlled and stable to reach agreement. If appropriate, involve the client in and is unlikely to spike unexpectedly. the exchanges. If disagreement persists, then the Shred of Doubt Principle prevails and the most conservative ● This patient’s spine is stable enough to withstand a level approach is best. 4 massage pressure, as in the attached pressure scale (see Chapter 2). ● OVERRIDING A PHYSICIAN’S INPUT ● This patient is at elevated risk of deep vein thrombosis, If opinions conflict, when is it appropriate for the massage and massage pressure in the lower extremities should be therapist to override the physician’s input or approval? It limited to level 1 or 2. depends on the circumstances. Several scenarios are pos- sible, and two of them are discussed here: In one, the phy- ● This patient’s hip is stable enough to withstand strong sician is more conservative, and in the other, the massage stretching or range of motion. therapist is more conservative. This yes/no format can serve as a follow-up measure to an If a physician supports a conservative massage plan, or incomplete response. Some therapists may also choose the no massage at all, in conflict with the therapist and client, yes/no format for an initial exchange (see Figure 5-2) to then it is unwise for the therapist to override the physician’s lower the chances of the form being “waved through” with- input. Even if the physician is not well informed about out close consideration of the therapist’s concerns. When- massage, or unresponsive to the client’s and the therapist’s ever it is used, the yes/no format can be very useful to the efforts to educate her, the therapist should stick with the massage session. However, in most cases, it should not sub- physician’s position. This might rankle some therapists, stitute for gathering information from the client himself. but let us consider the possibilities. Suppose a physician refuses to approve a massage plan for the client. Perhaps ● MANAGING CONFLICTING she advises against it because her own experience of mas- sage is that it is very deep and feels strongly that massage OPINIONS would therefore be harmful to the client. Perhaps she per- sists in her view, despite the massage therapist’s carefully In opening communication with a client’s physician, a mas- outlined, gentle, conservative massage therapy care plan. sage therapist opens himself or herself to possible disagree- This scenario is unusual, but it does happen. ment on the right course of action for the client’s massage sessions. This is not necessarily a bad thing. Dialogue The massage therapist is in an awkward position. He between massage therapists and physicians is necessary for believes that he can provide a perfectly safe, effective ses- coordinated care, and disagreement can be a positive sign, sion with modifications. The client and possibly even the that the physician is engaged in the issue and is seriously client’s family or friends are eager for the work, but the considering the therapist’s concerns. physician disagrees or will not approve it. The therapist is caught in the middle. Many therapists would be tempted Disagreement can take different forms and, in some cases, to go ahead and provide massage in this situation, but can include the client. For example, a client might feel that they should think twice. If anything goes wrong, such as massage is “no big deal” and that the consultation process is an adverse response to massage, or the client’s condition unnecessary, even if the massage therapist is in favor of it. worsens, the massage therapist who overruled the physi- A physician may join a client in the view that the therapist cian’s advice would be professionally vulnerable. The mas- is excessively conservative in his or her decisions. Or, a mas- sage therapist is accountable to not only the client and the sage therapist and client could favor a certain care plan, but the physician is concerned and will not approve the plan. The Shred of Doubt Principle can help massage therapists navigate this terrain. If any one of the three parties involved—client, massage therapist, or physician— disagrees with the others, a shred of doubt still exists about the massage approach. In this climate, the mostconservative
Physician Communication and Professional Liability 67 physician but also the client’s family. The answer to this kind time for correspondence. If a therapist has difficulty carry- of dispute is more education and dialogue, not rebellion. ing out communication with a client’s physician, the thera- pist must not complain to the client. The patient-physician Now, let us consider the other scenario: Suppose a physi- relationship is vital to the client’s care and is distinct from cian supports massage, but the therapist has doubts about the relationship the therapist has with either the client some elements. An example is a massage therapist who does or the physician. The alliance between a physician and a not feel comfortable applying strong pressure or circulatory patient is essential, as is the alliance between the massage massage, even after the physician has given the go-ahead and therapist and a client. the client wants it. The therapist’s hands and judgment are on the line, not the physician’s. The massage therapist does If, during a breakdown in communication between the have the right to refuse to provide work that he thinks might therapist and a client’s physician, the client wants to know be harmful, even if the physician and the client are in favor the progress of the exchange, the therapist shares the infor- of it. In this case, the therapist’s concerns override the other mation in a neutral, professional way: “I haven’t heard back perspectives. However, if the therapist intended at the outset yet, perhaps it’s because of the long weekend.” “I called to stick to a cautious massage plan, he might not have needed the office a couple of times yesterday, but didn’t receive a to seek the physician’s input in the first place. In “The Nurse’s return call.” “Your physician did not seem in favor of mas- Advice,” a therapist tells a story of working more conserva- sage, so I’m trying to find out more about his concerns so tively than a physician’s recommendation (see online). we can respond to them.” At first, it is important to use caution and follow up If a client complains about the physician’s nonresponse, on any information that suggests a contraindication. With or, for that matter, if she complains at all about the care she more dialogue and information, or a track record of positive is receiving, the therapist does not join in and gang up on client responses to the pressure, a less conservative mas- the physician, adding ammunition from her own experi- sage plan may develop over time. ence. Instead, she stays neutral and global in her response and sticks with reflective listening. “It sounds like you’ve The Where You Start Isn’t Always Where You End tried hard to get through to the office to get the form pro- Up Principle. Although a client’s condition may call for cessed. I’m sorry you’ve had to keep trying.” a conservative initial massage, stronger elements may be appropriate in later sessions, after monitoring the client’s Sometimes clients bring their complaints about their health response to massage over time. care to massage therapists. Within long massage sessions, there is ample time to express themselves. Again, reflective listening ● MAINTAINING ALLIANCES and neutral responses, not judgment, are the most supportive. The most important point is not to compromise the client’s On rare occasions, consulting with a client’s physician can care, or her alliance with her physician. Asking questions like be difficult, if not exasperating. This is usually due to the “Do you need to talk with someone about the care you’re heavy demands placed on medical personnel, leaving little receiving?” might be helpful. A therapist must remember her own role as a health care professional—she would not want a client and his physician to complain about her, either. Record Keeping In keeping with the therapist’s code of ethics, all corre- The therapist should also document how the physician’s spondence with a client’s physician should be kept confi- input was used in the session, for example, if he or she dential, with the client health record in a secure location. made adjustments to the massage based on the physician’s Electronic records must be stored in accordance with the advice. If the exchange was purely verbal, over the phone HIPAA privacy rules or other regulations. A record should or through the client, a written summary of the exchange be updated as needed, most often when new questions for should be included in the notes, along with the date and the the physician arise, or when the client’s health status wors- physician’s or nurse’s name. Even if communication with ens significantly. With an ongoing client, the therapist asks the client’s physician was unsuccessful or incomplete, the for a health update at each session and records the client’s details should be documented. If disagreement occurred response. If changes occur in the client’s report over time, between the therapist, client, and physician, specific points it may be time to revise the massage therapy care plan and of disagreement should be charted along with the therapist’s check it with the physician. massage plan. Physician Communication and Professional Liability Whether written or verbal, a physician consultation does therapist to seek safe haven under the umbrella of the phy- not automatically transfer liability from the massage thera- sician’s license in these decisions, it is not a true refuge. In pist to the physician. While it may be tempting for a the end, it is the therapist, not the physician, who worked
68 Chapter 5 Communicating with the Client’s Physician with the client, making the final decision about how and completed forms and careful charting can show that he or where to move his or her hands. It is the therapist who is she offered the massage plan to the client’s physician for considered responsible for any real or perceived harm, just comment and advice before proceeding. as the therapist is responsible for any therapeutic benefit. The sample communications in this chapter are not A physician consultation does widen the sphere of deci- designed to be legal documents; instead, they are tools for sion making to include the physician, and this good faith meaningful discourse between a massage therapist and a effort may, in some instances, be viewed favorably in the physician. The true purpose of physician communication unlikely event of litigation. If weighed in court, written is the well-being of the client. Any document planned for evidence of physician communication is much more reli- formal legal purposes should be reviewed by an attorney able than verbal recall, and a therapist with a paper trail of before it is used. The Benefits of Physician Communication The benefits of a physician consultation are broad and adjustments, made after necessary research and consultation, deep. By involving the client’s physician in massage deci- safeguard the health and well-being of the client. sions, the therapist models care and professionalism. By preparing thoughtfully and methodically for the exchange, Ongoing communication with other health care profes- the therapist enhances his or her own knowledge base sionals, especially when it is repeated, can lead to name rec- about massage and the client’s condition. The communica- ognition for the massage therapist. This, in turn, can lead to tion is an opportunity for the therapist to work responsibly referrals from medical offices. Therapist’s Journal 5-1 describes and collegially with other health care professionals. examples of professional alliances forged from this process. Everyone learns from such an exchange. Therapists broaden The massage therapy profession is developing rapidly, their knowledge of various medical conditions. Physicians and some therapists have less training in medical conditions broaden their understanding of massage therapy. Clients and massage contraindications than others. Determining may be empowered in the decisions that affect their health contraindications can be challenging. A temptation in the and massage treatment. And finally, responsible massage profession to lean on the simple “note from the doctor” might offer some comfort, but no real information. On THERAPIST’S JOURNAL 5-1 A Paper Handshake: Forms as Marketing Tools Usually following a conversation about my work, I hand the person my business card, with my name and contact information. In my practice, connection with my clients and the other practitioners in their circle of health care is valued. I prefer face-to-face communications, but initial community connections in business are often not in person. In these cases, I reach out with a paper handshake: a personalized mailing. At a massage course focusing on massage for people with cancer, I was introduced to a physician consultation form designed to assist communication between oncologists and massage therapists in regard to clients receiving massage therapy during treatment. After careful consideration of my audience (there was a palpable curiosity among physicians about the safe delivery of massage to cancer clients) and my own practice beliefs, I adapted this form to meet various needs. I renamed it a Cooperative Care Plan, signifying that each chosen health care provider involved is an invited guest in this client’s circle of care. Knowing that I am competently trained to deliver safe massage therapy for cancer patients, I utilized collaborative, nonhierarchical language in these revised forms. The result was a form that fostered cooperation and directly empowered the client’s voice in the process of healing. I sent a direct mailing of 200(+) to all health care providers listed by my clients on their intake forms and to all local oncologists. I personalized a warm letter, introduced my practice, and included my brochure and a blank copy of the Cooperative Care Plan. I did a combination of calls preceding the mailing and follow-up phone calls. This mailing planted the seed for future professional relationships. There were immediate return calls and referrals, and 100% of those contacted had positive feedback. But more importantly, the groundwork for trusted, competent delivery of services was initiated. I required a Cooperative Care Plan to be completed for all clients with cancer. Naturally, my reputation as a quality therapist and personality factored into the success of this mar- keting effort. But the forms we devise for our practices often are our signatures. This mailing was a significant tool in maintaining a thriving oncology massage practice of 6 years. Sarah Moore Sturges Le Mars, IA
The Benefits of Physician Communication 69 the other hand, a little research and preparation arms the with another health care provider, but therapists tell many therapist with tools and reduces his or her anxiety about the stories of productive communication and mutual respect. unknown, and it sets the stage for a meaningful exchange Focused on clear questions, bearing the goals of com- with a client’s physician. munication in mind, the therapist can guide a successful exchange that benefits the physician, the therapist, and, Over the course of a career, a massage therapist may ultimately, the client who deserves the care. weather an occasional unpleasant or hurried exchange SELF TEST 1. Suppose a client has a medical condition that raises 6. Describe the responsibilities that a massage therapist possible massage contraindications. Why is a simple should carry out before initiating contact with a client’s note from the doctor, approving massage, insufficient physician. for the massage therapist? 7. What are the disadvantages of communicating with a 2. A massage therapist plans to correspond directly with client’s physician through the client, without a written a client’s physician about the client’s medical history. record? Describe what the therapist needs from the client in order to contact the physician. 8. In correspondence with a client’s physician, how should the therapist describe the massage modalities that he 3. What are the four steps of a physician consultation? or she uses? 4. List three advantages of involving a physician’s nurse 9. If a therapist causes a real or perceived injury to a client in a medical consultation about the advisability of mas- with a medical condition, does written consultation sage therapy. with a physician transfer liability for the injury to the 5. What are the components of a massage therapy care physician? Why or why not? plan? List the advantages of having a standard mas- sage therapy care plan prepared for a certain client 10. In the event of a physician consultation, what should the population. therapist record in his or her client records about it? For answers to these questions and to see a bibliography for this chapter, visit http://thePoint. lww.com/Walton.
Chapter 6 Massage Research in Massage Practice Chapter 6 Massage Research in Massage Practice If we knew what it was we were doing, it would not be called massage. Knowledge of any adverse effects of massage is as important as knowledge of its benefits, since both can guide research, would it? the practice of massage. Ongoing sophisticated research will yield even more precise data about the “best practice” of —ALBERT EINSTEIN massage, refining therapists’ approaches to various clients. Best practice research compares different massage proto- As massage therapy becomes more visible to consumers and in cols, the massage dose, the best muscle groups to focus on, health care, the call for massage therapy research is growing and other factors in clinical success. When research shows stronger. Massage therapy is gaining ground as a health care a consensus about the best massage protocols to use for modality, and there is reason to look beyond individual client various clinical problems, these protocols will become part stories and chart some collective wisdom. of accepted massage therapy care plans for various clinical problems. Research can influence the profession of massage in many ways. Four of the principal contributions are: Many of the best practice guidelines in medicine are avail- able in the National Guideline Clearinghouse (NGC), avail- 1. Solid research in support of massage helps to promote mas- able on the Internet. At the time of this writing, the Massage sage therapy to the public, to other health care profession- Therapy Foundation has published a report outlining the need als, and to health care policy makers. for best practice guidelines and plans for submitting massage therapy guidelines to the NGC (Grant et al., 2008). 2. If research establishes health care cost savings with mas- sage therapy, it offers convincing evidence to policy makers A few massage studies at the frontier of massage research for the support of massage. have begun to look at best practice (Aourell et al., 2005; Cambron et al., 2006). From these and other efforts, the rich 3. Any documented adverse effects of massage can be used to knowledge in the profession will become easier to transfer: establish safety guidelines for massage therapy. from therapist to therapist, and from teacher to student. With this growing attention to massage, it is an exciting time for the 4. By documenting approaches that are most effective for profession. certain clinical presentations, research can direct the best practices in the profession. The first two research contributions address the basic ques- tion of whether to massage. The last two suggest how to A Collection of Stories Although research methods, language, and statistics can be Massage therapy wisdom has been passed along primar- intimidating to many therapists, a research study is simply ily by oral tradition. Therapists tell their stories to other one way to collect stories from people about massage. Each therapists, to massage students, and to their clients. While time a client leaves a massage session claiming, “My headache it’s important to relay these, it is also important to write is better!” or “The pain in my leg is gone,” he or she tells a them down. An experience of an individual client, handful story about massage therapy. Each time a pregnant or labor- of clients, or groups of clients in a massage research study ing woman tells her massage therapist, “Thank goodness you reaches a wider audience if it’s recorded in the literature. are here—it’s helping me through this,” it is a massage therapy Once such experiences are published, others can evaluate story. In research, these stories are systematically collected it, agree or disagree with it, and echo it from their own and analyzed, to determine whether they show clear cause experiences. and effect, and whether the same kind of massage can be help- ful on a larger scale in the general population. In Therapist’s The stories people tell about skilled touch and its impact on Journal 6-1, a massage therapist tells a story of a patient in a pain, sleep, anxiety and experiences of labor are compelling, massage study. and worth telling. Research is one forum for these stories, and is a good way to see if these individual experiences are shared As such, collections of individual stories, archived by by others—that is, if they are generalizable to a larger group researchers and told through research, can be as inspiring and of people. Clinical research attempts to answer this question: useful as individual testimonials from clients. They can build Could the intervention help a significant number of people, to a collective, shared understanding of the role and influence of a significant enough degree, to justify recommending its use massage therapy. for a given population? 70
The Current State of Massage Research 71 THERAPIST’S JOURNAL 6-1 The Night Before the Procedure One night at the hospital, after the dinner trays were cleared, I went to see an inpatient who was part of our massage study. She was scheduled for the active treatment, in a study looking at massage for people with advanced cancer. I knocked on her door and she invited me in. I introduced myself, and we chatted for a few minutes. I prepared my things, added pillows to support her, and we began the massage. I remember this patient well. She was quiet for much of the session, but as I massaged her feet, she began to talk. She told me about an extremely painful procedure that was scheduled for the next morning. She was dreading it. She told me she was even more afraid of how advanced her cancer was, that she was, in fact, dying. But her biggest fear was for her family. She feared for her husband and children. She had held their household together for years, and she worried about whether they could get along without her. She talked for a while, listing her fears, then rested again, more deeply as the session went on. I finished some data collection, then slipped out, quietly, so she could continue to rest. She gave me a sleepy wave. Clinical research is often seen as dry, cold, and analytical. My experience in this study, and on that particular evening, was otherwise; it was a deeply human exchange. The next day, the patient told the research assistant that she was astonished that she had slept better than she could have imagined that night. She was so grateful for the massage. Over the course of the study, we heard many stories like hers. In this population, improved sleep is a theme. So is easing painful procedures. As research on mas- sage continues to grow in the coming years, I am eager to see how these experiences are affected by massage. Tracy Walton Cambridge, MA Determining Clear Cause and Effect Conventional Western medicine is a world of evidence-based in independent variables and dependent variables, or cause practice, in which clinical decisions are often based on results and effect. In clinical research, an independent variable is of systematic research. Researchers ask one or more questions: a therapy or intervention that is manipulated by a researcher Did the massage cause the desired effect, or was it due to to see if it affects another factor, the dependent variable. In a something else? If massage has an effect, what quality or fea- massage study, massage therapy—say, the presence or absence ture produced that effect? How do we design further research of it, or the dose or frequency of it—is the independent vari- to learn about cause and effect? able. A dependent variable is an outcome of an experiment, measured to see if it does, in fact, depend on the independent Researchers are interested in variables, or things that change variable. Dependent variables are usually signs or symptoms, in a study. For example, if we vary the length of massage, will such as back pain, sleep quality, blood pressure, or relaxation. the client’s back pain vary, as well? This question is expressed The Current State of Massage Research The massage therapy profession has benefited from small stud- steps when published. Sometimes the researchers’ own bias in ies of massage over the last few decades, much more in the favor of massage influences the study results or the tone of the past 20 years. After so much time without recognized research, report. Often published studies report a cause and effect rela- the profession has welcomed this development, and in some tionship between massage and patient improvement, but the cases, has embraced the available research without questioning investigators haven’t accounted for other possible explanations it. However, in many cases, too much has been made out of for the improvement. the small body of research. The profession is just beginning to incorporate the high standards of research use and design that The available research is frequently given too much weight are characteristic of medicine. Instead, the credibility of mas- in massage-marketing materials, trade journals, and texts. sage therapy still suffers from the ways research has been used: Many of the claims made about massage have little or no research behind them, or the research is not conclusive. The ● Citing massage research of uneven quality profession is on stronger ground when massage therapists carry ● Overstating results from small studies out the following responsibilities: ● Making too much out of a single study, rather than quoting 1. Make accurate claims about massage. Look closely at the a body of literature on a research topic statements that are commonly made about the effects of massage, and whether they are supported by research or by While the body of massage research is growing, it is still small, thoughtful clinical observations. and in many cases, it is too early to draw strong conclusions from it. Some studies have been poorly designed and poorly 2. Use research accurately. Avoid overstating available research, reported, without explicit mention of important data or design and recognize strengths and limitations in published research.
72 Chapter 6 Massage Research in Massage Practice Distinguish between stronger and weaker levels of evidence Massage therapists do not have to become research experts, in massage research. and not all therapists are drawn to it. But research is more 3. Track massage research. Follow the development of accessible and interesting than it often appears, and everyone research in a topic of interest, such as massage and benefits from good research. The Internet makes it easy to back pain, massage after surgery, or massage and cancer find, appreciate, and use. symptoms. 4. Treat clinical work as a form of research inquiry. Focus on From the list above, the first two areas of focus are ethical therapeutic outcomes, and use measurement tools from and professional responsibilities, expected of all health care research to determine what is effective for different client providers. The last two may interest some therapists more than presentations. Document and share successes and failures. others. Each area is discussed in this chapter, with suggestions and resources for implementing it. Making Accurate Claims about Massage There are many building blocks of evidence-based medicine, writing. The claim about massage and circulation is the most and the massage profession is beginning to adopt them. Sev- deeply rooted of the three, but, in fact, the evidence to sup- eral key concepts in medical research are explained below, port it has not yet arrived. with applications to massage therapy: Unfortunately, these claims about circulation, endorphins, ● Research reviews and the immune system have been made for so long that ● Randomized, controlled trials (RCTs) they are deeply ingrained in massage promotion, practice, ● Sufficient sample sizes and instruction. Therapists have repeated them innocently ● Levels of evidence enough, without knowing the gaps in the evidence. But it’s better for the profession to recognize its lore, and drop it Even as the profession moves toward an evidence-based from the many lists of massage benefits. If solid, convincing approach, many unsubstantiated claims are being made research emerges one day in support of these claims, they about massage therapy. In fact, some of the most often- may be reinstated. Until then, they verge on false claims about repeated claims about massage have the least research sup- massage therapy. More humble and accurate claims, based on port. Table 6-1 lists three of the most common claims about clinical observations and the intent of massage, also appear in massage, along with the status of research at the time of this Table 6-1. Using Research Accurately Massage trade journals, promotional materials, and massage work on a topic than a single study, and assess the pool of evi- training curricula have made strong statements of weak dence. To review the evidence adequately is a daunting task, research, using it to “prove” the claim of massage benefits. Yet, however, and one might have to look through many studies undeniable proof is not a common thing, even in medical sci- to determine which ones are strong enough to include in the ence. Even when research makes a statement, it is not always assessment. Limitations on time, resources, and expertise make definitive; a single study does not prove a point. Instead, a study this impossible for most health professionals. Instead, they rely needs to be around for a while, reviewed by other experts in on research reviews by experts. There are two types of research the field, and considered alongside other evidence from other reviews: the narrative review and the systematic review. Think investigators in order for firm conclusions to be drawn. In of a review as “a study of the studies” on a topic. medicine, a number of studies from different researchers are typically necessary in order to say that there is clear cause and The Narrative Review of Research effect between a therapy and a therapeutic outcome. In a narrative review, researchers focus on a topic of interest By simply avoiding the word proof, and using more moder- and search the medical literature for relevant studies. They ate language, such as “research suggests,” or “research sup- might decide to look at general massage effects, or the effects ports,” a therapist is already in more honest territory. In more of massage on a given problem or population. They report on clear-cut cases, discussed below, a therapist might even be able their findings: the number and strength of the studies, and the to say “Strong evidence for massage benefit is shown in the direction that the evidence seems to lean. They do not subject following research review: ___.” In general, a dose of humility the studies to any statistical tests, as is done in the systematic when making massage claims, or any claim, is well received in review, but give their impressions of the available data. Done an evidence-based medical world. well, a narrative review is given more weight than any single study. ● USE A BODY OF RESEARCH Although a narrative review is a broad synthesis of other VERSUS A SINGLE STUDY studies, it is still subject to the bias of the reviewers, especially in the selection process. The reviewers’ own preferences and In fact, even the most well-designed study does not stand alone relationships with other researchers may influence the stud- as convincing evidence of a therapeutic effect. Any one study, ies that they select to include in the review. Still, narrative no matter how large or well constructed, could be vulnerable reviews can be valuable compilations of data on a topic, even to the bias of the research group, or a mistake along the way though there is no formal statistical processing. On topics of that wasn’t caught. It is better to look at the whole body of
Using Research Accurately 73 TABLE 6-1. COMMON CLAIMS ABOUT MASSAGE Status of the Evidence “Massage increases circulation.” References As of this writing, only a handful of studies exist on massage and circulation, all are small, More Accurate Claim and the results are mixed. Older studies with less sophisticated measurements suggest that Massage Intent massage increases blood and lymph circulation. The information from more recent studies, using ultrasonography and other measurement techniques to measure circulation, is incon- clusive. Weerapong et al. (2005); Mori et al. (2004); Hinds et al. (2004); Taniwaki et al. (2004); Morhenn (2000); Agarwal et al. (2000); Shoemaker et al. (1997); Tiidus and Shoemaker (1995) It’s too early to say whether massage increases circulation at the site of massage, or increases systemic circulation—the evidence is unclear. In clinical practice, we observe tem- perature and color changes at the site of massage that may be attributable to a change in circulation. When appropriate, we work with the intent to increase circulation. “Massage releases endorphins.” Status of the Evidence As of this writing, only two small studies, published 20 years ago, have looked closely at massage and endorphins. One found no change in endorphins using Swedish techniques. References The other suggested some change associated with a specialized form of connective tissue More Accurate Claim massage, not with common techniques. Massage Intent Kaada and Torsteinbo (1989); Day et al. (1987) There is insufficient evidence to answer this question—we don’t know whether massage acts directly on endorphins. In clinical practice, our clients commonly report pain relief during and after massage. Whether endorphins are responsible for this has yet to be seen. The body of research on massage for pain, stress, and quality of life is growing, though, and it will be interesting to see what is found. We practice with the intent to relieve pain and increase well-being. Status of the Evidence “Massage boosts the immune system.” References More Accurate Claim As of this writing, only a handful of small studies report this claim, and the body of evidence does not conclude that massage enhances the immune response. Massage Intent Hiller et al. (2010); Billhult et al. (2008); Hernandez-Reif (2005); Hernandez-Reif (2004); Shor-Posner et al. (2004); Diego et al. (2001); Goodfellow (2003); Field et al. (2001) We don’t have enough research to know how massage affects immunity. In clinical practice, our clients report stress relief and increased well-being. It is possible that these factors influ- ence immunity. We practice with the intent of reducing our clients’ stress and supporting their well-being. great interest, there may even be multiple reviews by multiple on a topic, mining it for suitable studies that meet explicit, authors. One example of this is massage for people with can- rigorous selection criteria. As part of the process, the revi- cer, with reviews by Corbin (2005), Myers et al. (2008), and ewers make note of the studies that are most vulnerable to Weiger et al. (2002) (see online bibliography at http://thePoint. bias. Their selection methods are transparent and open to lww.com/Walton). Narrative reviews provide important com- scrutiny because they are published in the review. If the stud- pilations of data on a topic, even though there is no statistical ies generated by a systematic review are comparable enough, processing. the reviewers can use established statistical methods known as meta-analysis, or meta-analytic methods to treat the col- The Systematic (Quantitative) lection of different studies as one large study and determine whether an intervention convincingly produces a given out- Review of Research come. Assuming this is done according to protocol, with a minimum of bias, the information it generates is extremely In evidenced-based practice, a systematic review is given the useful. Using meta-analytic methods, the systematic review highest ranking (see “Levels of Evidence,” this chapter). It is has the advantage of assembling larger numbers than is pos- given more weight than a narrative review, because it includes sible with small studies. statistical processing of available studies. It pools the data from multiple studies that meet specific standards. The systematic review is a powerful tool for answering research questions, and in establishing results that can be gener- In a systematic review, the gold standard in research, alized to large numbers of people. After going through the review reviewers use quantitative methods to determine whether a process, authors typically return one of three conclusions: therapy is effective. They begin by searching the literature
74 Chapter 6 Massage Research in Massage Practice 1. That the therapy appears to be effective enough to warrant (RCCT). The steps of an RCT are shown in Figure 6-1. There current practice or wider use. are several key features of an RCT: 2. That the therapy does not appear to be effective enough to ● It is a prospective study, planned ahead. warrant current practice or wider use. ● There is a control group or control condition, used for compar- 3. That the number or strength of the available studies is too ison, that does not receive the active treatment being tested. small to determine the effectiveness of the therapy, and it is ● Research subjects are randomly assigned to either the con- too early to say for sure, in either direction. trol group or the active treatment group. Systematic reviews often include suggested directions for fur- ther research, which can help guide researchers in the area. Prospective Study In health and medicine, the most widely recognized source A clinical trial, by definition, requires planning. An RCT is of systematic reviews is the Cochrane Collaboration, which prospective: it looks forward, not back. Researchers plan to maintains a searchable database on the Internet. A Cochrane study future behavior, not past behavior (as in a retrospective Review is a systematic review on a topic in medicine, includ- study). In the case of a massage study, investigators plan a ing massage therapy and other CAM therapies. The reviews massage intervention to see how it will affect the sample. This performed by the Cochrane Collaboration fit well-established is different from, say, a study that examines a group of people protocols, and are therefore a reliable source of information who have well-managed symptoms of a chronic disease, and for this level of evidence. Cochrane reviews are updated interviews them about whether they’ve used massage therapy periodically, and it is possible to simply view the abstract in the past 6 months. and a plain language summary or the full text of the review. Cochrane reviews have been performed on topics such as: Control Group or Control Condition ● Massage and HIV/AIDS (Hiller et al., 2010) Another essential component of a controlled trial is a control ● Massage and touch for people with dementia (Hansen group or control condition. In clinical research on massage, medication, or any other therapy, a control group is a group et al., 2006) of people who does not receive the therapy being tested. The ● Effect of massage on preterm infants (Vickers et al., 2004) same outcomes are measured in the control group to provide ● Deep transverse friction massage for tendinitis treatment a comparison for the effects of the treatment (see Figure 6-1). Suppose 100 people receive back massage and their (Brosseau et al., 2002) pain is relieved over the course of the study. How can one ● Effect of massage on low back pain (Furlan et al., 2008) tell whether most of them would have gotten better anyway, ● Massage for infants (Underdown et al., 2006) without the massage? Without a comparison, the evidence ● Massage for mechanical neck disorders (Haraldsson et al, for massage providing back pain relief would not be very strong. In fact, most of the time, back pain tends to improve 2006) on its own. Although the Cochrane reviews are known sources, other If this same study were done in a controlled fashion, some journals also publish reviews. There are systematic reviews of the subjects would receive massage, and some would not. on massage therapy (Moyer et al., 2004), and a great deal of The massaged group is called the active treatment group recent attention to massage and cancer (Ernst, 2009; Jane or experimental group, the group of subjects that receives the et al., 2008; Wilkinson et al., 2008). treatment being tested. By comparing them to the control (non-massage) group, one can get a sense of whether they ● THE RANDOMIZED, would have gotten better even without the massage. CONTROLLED TRIAL In clinical research, the prevailing standard in research design is the RCT, or the randomized, controlled clinical trial Pre-intervention Post-intervention (baseline) measurements measurements Sample Randomization Active treatment Active treatment Pre-post data from group group both groups Receives massage compared to determine effect of massage Control group Control group Receives no massage FIGURE 6-1. A RCT of massage therapy. Research subjects are randomly assigned to the massage or control group, using the elec- tronic equivalent of the flip of a coin. Measurements are collected from both groups at baseline and after the intervention, and data from both groups are compared to determine any effect of massage.
Using Research Accurately 75 If researchers observe that both the control and the active those receiving the massage intervention first, there may be treatment groups improve by about the same amount, it sug- a “holding period” before their control data are collected, so gests that the massage had no effect. On the other hand, if the that the effects of the massage don’t carry over into the con- difference in the two results is significant, then the improve- trol period. Crossover designs have many advantages, in that ment in pain is probably a true effect of massage. the control and active treatment groups are the same people, and each person generates two sets of data. A crossover design A control condition is a research condition experienced by also satisfies any ethical concern over one group being denied participants in a control group, to provide a comparison to the treatment. active treatment being tested. During the control condition, often subjects receive only usual care (UC), also called stan- In a crossover study of foot massage in a hospital (Greal- dard care (SC), the typical medical care for their condition. In ish et al., 2000), inpatients were assessed on three different a medical setting, UC includes all the normal ways in which evening occasions: on two evenings, they received a 10-minute patients are treated, with medications, procedures, and so on. foot massage and were measured before and afterward. On a third night, they received no massage intervention, but In some massage studies, control groups get another kind had quiet time for the same time period and were measured of treatment, such as imagery aimed at relaxing muscles. To before and after the quiet time. These patients “crossed over” be sure that massage effects aren’t just a function of a caring from one condition to the other. Figure 6-2 shows a crossover interaction or the good nature of a massage practitioner, design; compare it to the parallel design in Figure 6-1. researchers might make the control condition a visit, with no touch (Post-White et al., 2004; Smith et al., 2002). If a visit WAIT-LIST CONTROL turns out to be just as productive as a massage, a friendly vol- unteer might be capable of achieving the same positive results In a wait-list control design, everyone in the study receives as a trained massage therapist. some form of active treatment, but one group, the control group, has to wait until the end of the study to receive it. It Another investigator might ask whether the movement in starts as a parallel design, with an active treatment group and most massage strokes is important, and compare non-moving a control group, and any baseline measurements. touch with moving touch (Kutner et al., 2008). Yet another researcher might compare less skilled touch, for example, from After they complete their measurements, those in the massage students, nurses, or lay people, to touch from profes- control group receive some form of active treatment. This sional massage therapists, to see if the training makes a differ- could be a lesser intervention, such as only a single massage ence in the outcome. As the profession advances, more research in a study where active treatment subjects received a several- will appear comparing different types of massage protocols for week course of massage therapy (Figure 6-3). On the other a given problem, helping to determine the best practice, and hand, some researchers add the wait-list control subjects to the massage elements that are most important in a therapeutic the active treatment group at that point, and they receive the outcome. full dose, with the usual data collection. This yields an active treatment group that is larger than the control, but it generates Researchers incorporate control conditions differently, and more data. In either case, the wait-list control is an appealing different types of control conditions are possible. Some of these design, because it provides a kind of “consolation prize,” or possibilities are: incentive for the control subjects to complete the study. Data collection can suffer when control subjects, dissatisfied with ● Parallel design their group assignment, drop out of the study. ● Crossover design ● Wait-list control ATTENTION CONTROL ● Attention control ● Sham control (or placebo) In an attention control, researchers attempt to answer the question, “How much of massage therapy benefit comes from PARALLEL DESIGN the skilled touch, and how much of it is due to the attention that the therapist gives the client?” In an attention control, the group One of the most common RCT designs is a parallel design. receives some other form of attention, such as the friendly visit, In this case, the research subjects in the control condition described above, being read to, or otherwise being given atten- and others in the active treatment go through their respective tion. This can also reduce the loss of data due to subjects drop- conditions and measurements in parallel (see Figure 6-1). ping out of the study. They are usually assessed at the beginning to obtain baseline measurements of the outcomes of interest. In a parallel design, THE PLACEBO EFFECT AND because the control group does not receive the active treat- THE SHAM CONTROL ment, research subjects from that group may be more likely to drop out of the study, leading to a loss of data. Choosing the right control condition takes some thought on the part of a researcher. By far one of the most difficult con- CROSSOVER DESIGN trols to provide in massage research is a placebo. A placebo gives the suggestion of an active treatment; it is a substance In a crossover design, all the participants in the study have (such as a sugar pill) or procedure that is designed to the same experience, receiving the full active treatment as well resemble the active treatment, but has no known therapeutic as the control condition, and cross over from one condition to effect. The placebo effect is a positive effect attributed to a the other at some point. In a crossover design, shown in Figure participant’s expectation that she or he will be helped—that 6-2, each study subject serves as his or her own control, and is, from simply believing in the potential for improvement. data are collected for both conditions. In this case, the subjects may be randomized, but only to determine the order in which they receive massage therapy and the control condition. For
76 Chapter 6 Massage Research in Massage Practice Pre-intervention Post-intervention Pre-intervention Post-intervention (baseline) measurements measurements measurements measurements Sample Randomization Group A Active treatment Subjects Active treatment Active treatment Group A’s receive cross Group B’s receive and Control data massage over massage generated from both groups, having both experiences Group B Control Condition Control Condition Group B’s receive no Group A’s receive no massage during this massage during this period period FIGURE 6-2. A crossover design in a massage therapy RCT. In contrast to a parallel design, research subjects in a crossover design experience both the control and massage condition, but in different sequences. The order is determined at random. After a subject experiences the first condition, measurements are collected and the subject proceeds to the second condition. Measurements are repeated for the second condi- tion. When crossing over, subjects may have to wait a minimum “washout period” for the effects of the previous condition to wear off. The placebo effect, or nonspecific effect, is not a specific previously, some patients crossed over twice, from foot response to the active treatment. In order to isolate the pla- massage to quiet time to foot massage. The sequence of the cebo effect, researchers often use a sham control or sham single control and two experimental evenings was determined condition. The sham control is a substance or procedure that by a random process so that different patients received the may be similar to the active treatment, but missing a key interventions in different sequences. feature of the active treatment. In a sham acupuncture ses- sion, needles are placed, but not at the therapeutic points. Randomization also helps produce control and experimen- A sham is designed to lead the subject into thinking he or tal groups that are comparable at the outset, by mixing in any she is receiving something valuable. This is difficult to do in elements in the sample and distributing them evenly between massage therapy. How do you make a person think he or she groups. For example, suppose a number of unusually relaxed is being massaged, when he or she’s not? There is no obvious people enroll in a massage study, in which the experimental sugar pill here. treatment is a weekly massage over 4 weeks. Some massage modalities are more conducive to sham Because researchers hope for equivalent groups, they procedures than others. Modalities with highly choreographed would want these unusually relaxed subjects to be evenly protocols, such as reflexology, acupressure, and manual lymph distributed over the two groups so that they don’t confound, drainage, can be tested against a sham protocol that violates or muddy the results. A confounding variable accentuates the correct sequence or placement. Specialized protocols are or obscures the apparent size of a treatment effect. It makes mysterious to most clients, so they can’t tell the difference it hard to determine clear cause and effect. In this example, between an actual therapy and a placebo. On the other hand, the relaxed subjects might have especially favorable responses with Swedish massage, more familiar to recipients and more to massage, because they are already relaxed, and are open to variable in protocol, it’s harder to “fool” the client. massage and its positive effects. Or they might have unfavor- able responses to massage, because they are already so relaxed Random Assignment of Study Subjects that massage cannot relax them much further. If too many of these subjects are assigned to one group or another, they might Another key element of the RCT is randomization. This artificially enhance or diminish the apparent effect of massage, refers to the assignment of study subjects to their groups. and randomization removes their choice in the matter. Group assignment is random, that is, generated by the elec- tronic equivalent of a flip of a coin. Neither the subject nor It is impossible to completely keep a sample perfectly the researcher has a choice about which group the subject is “clean,” the groups perfectly balanced, or a study free of con- assigned to. If entering a crossover study, each subject goes founding variables, but their influence can be minimized as through all the interventions, but the order of the interventions much as possible. Randomization can help limit this problem. is random. In the three-night foot massage study, discussed Randomization is also a vital feature in reducing bias in a study. Bias is any type of influence in a study that leads to error
Using Research Accurately 77 Pre-intervention Post-intervention (baseline) measurements measurements Active Treatment Active treatment (massage) (massage) Group A’s receive data collected massage and are measured Control data collected Sample Randomization Group A Group B Wait-List Control Active Treatment Group B’s receive no (massage) massage, but are Group B’s receive measured some amount of massage; either equivalent to group A or less FIGURE 6-3. A wait-list control design in a massage RCT. After control subjects have completed the control condition and their data have been collected, they are given the active treatment. by favoring one outcome over another. Bias can come from the blind everyone on a study staff: a massage therapist providing investigators and the participants. By randomizing, neither the the treatment knows whether or not she is providing massage. investigator nor the research subject can decide which group the So researchers blind whomever they can blind. For example, subject is assigned to—the control or active treatment group. If the data collector, who takes measurements after the session, research subjects were given a choice and the treatment was can enter the room with the study subject and take measure- promising, and not uncomfortable, most people would choose ments without knowing whether a massage or control condition to be in the active treatment group. In fact, many people enroll took place. If the participant doesn’t reveal the intervention she in a study with that hope. Their expectations could skew the just had, then observer bias can be reduced. Ideally, researchers results in favor of the treatment. Knowing a research subject’s describe the blinding process in the published research paper. bias, an investigator might be tempted to enroll them in the active treatment, to contribute to favorable results. Instead, ● SAMPLE SIZE randomization distributes that bias across both groups. The number of people enrolled in a study, whether small or Blinding large, is called the sample size, expressed as the letter n. Many studies in massage therapy are too small to be convincing. If a Another way of reducing bias is by blinding, or concealing the sample size is too small, it increases the chance of the sample group assignments of the research subjects from the investiga- being atypical in some way, not truly reflecting the population tors or from the research subjects, or both. In single-blind of interest. For example, suppose a researcher chooses a sample studies, the subjects themselves are blinded. Their lack of size of 10 for a study on massage and symptom relief in multiple knowledge about the treatment they are receiving (or not) sclerosis (MS). With such a small sample, there is a chance that may diminish the placebo effect, because neither group knows seven or eight of those would be unusual in some way—they whether they are receiving the active treatment. This can, in might be under remarkable stress, or exceptionally averse to kind, limit the influence of their personal bias on the outcome. massage, or have other factors that make their MS symptoms This is easy to implement when there is an obvious placebo hard to relieve. This would leave only two or three “average” such as a sugar pill, because the pill looks like an active treat- subjects with MS. Any one of these factors might diminish the ment. As discussed earlier, it is more difficult to achieve this influence of massage in this sample of 10, where a larger, less in a massage study. skewed sample could demonstrate the true effect of massage. On the other hand, other factors might artificially amplify the In a double-blind design, both researchers and participants apparent effects of massage. And the small sample size, less are in the dark about group assignment. It can be difficult to
78 Chapter 6 Massage Research in Massage Practice likely to reflect the average MS patient, makes it difficult to Strongest Systematic Review generalize the results, to the larger population of patients. Evidence Narrative Review Studies with larger numbers are less vulnerable to these Weakest Randomized, influences, and it is easier to generalize from them. They are also Controlled Trial more expensive to carry out, and less common than small stud- FIGURE 6-4. Levels of evidence. Evidence Case Series ies. In any field, research begins with small studies and grows, over the years, to larger ones. In fact, many of the studies in Case Report massage are pilot studies. A pilot study is a small, exploratory study designed to begin answering a simple research question, Anecdote scout the territory, determine whether research in the area is feasible, provide direction for further inquiry, and gain fund- aches, and data are collected with symptom questionnaires. ing for larger, more substantial studies. Randomization produces two groups: a massage group and a control group, receiving UC for headaches. Many of the studies in massage therapy are pilot studies. 5. Narrative review (see description, this chapter). A resea- Even if they suggest robust massage benefits, the numbers rcher reviews the literature on massage and headaches and are not usually large enough to draw firm conclusions. At the publishes his or her impressions of themes that emerge in same time, small studies are vital in supporting further study the studies, the strength of the research designs, and the and gaining visibility for massage. direction that the evidence seems to be leaning. No quanti- tative methods are used. There is no magic number that designates a credible study. 6. Systematic review (see description, this chapter). A rese- Researchers consider many factors, including the expected archer collects studies on massage and headaches using effect of massage, when determining an appropriate sample predetermined screening criteria. The evidence is analyzed size. In general, research with several hundred subjects is using strict statistical methods (meta-analysis), and the more convincing than a sample that is less than 100. But there strength of the studies and the direction of evidence are are other aspects of research design that are also important, used to formulate a conclusion about massage and head- and a large sample size does not compensate for poor design. aches. This type of evidence is considered the strongest. ● LEVELS OF EVIDENCE The first three levels of evidence are observational, and can be gathered from a therapist’s notes on her own clinical practice. In evidence-based practice, evidence is ranked according to The second three levels are analytical and quantitative. These a hierarchy of strength and credibility. This ranking is called projects are more calculated and planned, involving a lot of the levels of evidence. The systematic review is at the top of additional thought and expertise. the hierarchy, shown in Figure 6-4. There are many levels of evidence. The main ones, from weakest to strongest, are listed Even though the first three levels of evidence—anecdote, below with a massage therapy example: case report, and case series—are clinical observations, they can include formal measurement of outcomes. Therapists 1. Anecdote. A single, informal story from clinical practice, typically ask their clients about responses to treatment and such as a client whose headache is relieved after a massage can document these responses using various scales and symp- session, or a series of sessions. This evidence is the weakest tom checklists in the literature (see “Visual Analogue Scale,” in strength, at the bottom of the hierarchy. this chapter). Such measurement tools help therapists notice trends or patterns in their practices and keep track of how 2. Case report. A formal account, written by a practitioner, of a clients are doing. single client’s background, presentation, treatment, and out- comes. A case report might tell the story of a client whose The levels of evidence provide a visual reminder that a sin- chronic headaches reduced in frequency and severity after gle RCT does not necessarily prove something. Even though a course of massage sessions. much of the massage research is in RCT form, the RCT has to be well designed and implemented to be taken seriously. And 3. Case series. A formal write-up of several case studies, typi- it takes a number of good RCTs, pooled in a systematic review, cally with similarities in presentation and treatment, that to make firm statements about a therapy’s effectiveness. Of helps highlight similarities and differences among the cases. all of the levels of evidence, the most persuasive conclusion Several clients with chronic headaches, the therapist’s treat- comes from a systematic review. ment approach, and outcomes would be discussed in a case series on headaches. 4. RCT (see description, this chapter). Massage treatments are tested on a group of study subjects with chronic head- Tracking Massage Research Most massage therapists have an interest in a special population ● PubMed. This searchable index of medical research is pro- of clients, or in certain clinical problems and successes. By vided by the U.S. National Library of Medicine at the National checking the research literature on those topics, a therapist Institutes of Health. It is possible to retrieve research articles may find shared interest, inspiration, and support for her work. as recent as the current month. Type in “massage therapy” To check for systematic reviews and studies, scout established and a topic of interest, such as dementia or arthritis. databases on the Internet. Usually, searching for “massage therapy” and a topic of interest yields a number of results. ● The Massage Therapy Foundation. This nonprofit orga- Each of the databases, below, is a unique research resource: nization provides a database of research articles that are not all indexed on PubMed, as well as other resources on
Approaching Clinical Work as a Form of Research 79 massage research, education, and community service. The Although finding research citations is relatively easy using the foundation publishes, online, the open-access International Internet, retrieving the full text articles can be trickier. A por- Journal of Therapeutic Massage and Bodywork, which tion of papers are available for free on the Internet, but many includes research as well as articles on clinical practice and require more digging: paying for document retrieval services, massage education. using a medical library, or asking a health care provider to pull ● The Cochrane Collaboration. Full text systematic reviews the paper from a hospital or clinic library. Some people write are available for purchase, and summaries in plain language to the first author listed on a paper to request a reprint. are free. ● The NIH RePORT (Research Portfolio Online Reporting While not all massage therapists will actively participate in Tools). The RePORTER database is an index of active research, it is important to acknowledge the research available research projects in the United States, funded by the in the literature. One way to think about research is as a con- National Institutes of Health. Unlike the other databases sumer. Any taxpayer is a consumer of research, because some of published research, this resource catalogues research tax revenue goes to government-funded medical research. projects that are still in progress. Typing in “massage As recognition of complementary and alternative medicine therapy” and a topic of interest yield listings of projects, (CAM) therapies grows, more funding goes to CAM research, names of investigators, locations, and short summaries of and taxpayers can evaluate publicly tended studies. Although the research in process. many people think evaluating research is the domain of schol- ● Clinicaltrials.gov. This registry includes active clinical tri- ars and funding organizations, massage professionals can do als in the United States and at least 170 other countries. It it, too. Several excellent books are available to help massage serves as a clearinghouse for publicly and privately funded therapists use and design research (Travillian, 2011; Menard, projects. 2009; Hymel, 2006; Field, 2006). Research literacy is fre- quently discussed in professional journals. Approaching Clinical Work as a Form of Research In various ways, active massage therapists are already perform- therapist’s documentation, and focus the therapist’s attention ing research themselves. They are already learning from their on what is and isn’t working. clients. Therapists study their clients’ responses to massage, and try to determine the treatment that will optimize the The Visual Analogue Scale outcome. With a curious mindset and a few simple, standard- ized measurement tools, a massage therapist can enhance this A visual analogue scale (VAS) is a numerical scale that pro- learning process. vides a system for a client’s self-report of symptoms. They come in various formats, but a VAS is usually a simple line, 10 cm long, ● USING COMMON MEASUREMENT with only the endpoints labeled as anchors: 0 and 10 (Figure 6-5). The endpoints are also labeled with a symptom or experi- TOOLS ence, such as pain, anxiety, relaxation, or fatigue. The respondent draws a hatch mark on the line that indicates how her symptom Easy-to-use checklists and scales, common to research and is at the moment. Later, the researcher measures the line with practice, can be used before and after a session to get a sense a ruler to see where the hatch mark appears, and the number of how the client is responding to massage therapy. These are is likely to be returned as a decimal, such as “7.1” or “5.3” In called pre-post measurements, and they can also be used clinical practice, the VAS is easier to use with pre-labeled hatch periodically over a course of treatment. Pre-post measure- marks added at numbers 1, 2, 3, and so on (see Figure 4-2). ments, also called before and after measurements, enhance the Please draw a line on the following scale that shows how you are feeling right now. 0 10 No Worst pain pain possible Please draw a line on the following scale that shows how you are feeling right now. 0 10 No Worst headache headache possible Please draw a line on the following scale that shows how you are feeling right now. 0 10 Totally Worst relaxed anxiety and calm possible FIGURE 6-5. Samples of the VAS. Many symptoms and internal experiences can be described in a VAS.
80 Chapter 6 Massage Research in Massage Practice The Verbal Rating Scale Regular questions about symptoms and scales may appeal to many clients, but can put off others who prefer massage as The verbal rating scale (VRS) is a verbal version of the a retreat, rather than another goal-oriented experience. For VAS, another way to self-report symptoms or internal experi- some people, answering questions or rating symptoms can be ences. A VRS takes less time than a VAS, because it is a natural stressful; a sensitive therapist can determine who might want part of conversation before and after a massage, and it does not to evaluate her own experience, and who needs a break from require pen and paper to complete. it. During some of the most profound human experiences of illness, injury, and other life crises, many people would rather Here is an example: On a scale of 0–10, with 0 being no be ministered to instead of questioned and fixed. By reading a pain and 10 being the worst pain possible, how do you rate client’s cues, a therapist can be of service in multiple ways. your pain in this moment? ● DOCUMENTING AND Here is one on relaxation and anxiety: On a scale of 0–10, with 0 being totally calm and relaxed and 10 being the worst SHARING CLINICAL WORK anxiety possible, how do you feel right now? Therapists who document these things closely, using SOAP notes Often the response to a VRS is a whole or half-number, or some other consistent format, can learn much from their prac- such as 4 or 7½. Other fractions or decimals are unlikely. tice. When interesting things emerge in the practice, therapists Research on VASs and VRSs suggests that similar data are should write them down! Even a small amount of feedback, such generated from the two formats (Cork et al., 2004). as the following, may evolve into a whole system or care plan: VASs and VRSs are quick and convenient to use for symp- I worked certain muscles at their attachments to the toms such as pain, fatigue, nausea, depression, alertness, or occiput, and focused especially on the sternocleidomas- any internal experience. toid (SCM) attachments. I followed this with 10 minutes of massage to the shoulders and back. The client reports Other Measurement Tools that her headache eased during the massage and went away within an hour after the session. The client has been In addition to VASs and VRSs, a massage therapist can find mea- headache-free for 2 weeks. surement tools for just about any symptom or experience. On the Internet, by using search terms such as “clinical research,” Enough careful observations such as these, along with sup- “checklist” or “questionnaire,” “symptom,” and a topic of inter- porting information, may also be shaped into a short article est, a therapist can locate symptom checklists, and common for a trade journal, thereby inviting dialogue from readers. scales for many symptoms. Standardized tools are available for A therapist can use the resources of the Massage Therapy parameters such as daily function, anxiety, and even spiritual Foundation to develop a case report from her observations. By quality of life. By looking around at massage research, a thera- attending professional conferences, then sharing case reports pist can find measurement tools for his or her clinical interests. with other therapists, and inviting feedback, therapists can find support to further their clinical work. ● REMAINING OPEN TO FINDINGS Massage therapists hear many stories from their clients— One of the most important traits in a researcher is the ability to compelling stories of symptoms, successes, athletic perfor- be open to different outcomes. This is true in clinical practice, mance issues, and all of the challenges people face in their too. Even the most results-oriented therapist recognizes that bodies as they go about their days. While the clinical work it is possible to become too narrow in focus, or too carried doesn’t need to stop and wait for science, good documentation away with outcomes. Many wonderful things happen in mas- of clinical work will help contribute to the science of massage sage when you are not trying too hard. By using an approach therapy. that is too goal oriented, a therapist may miss other important information. How Research is Used in This Text Every effort is made to include thoughtful massage claims and that is also noted in this section. Therapists are advised to careful use of research throughout this book. There are several recheck resources periodically, as more research may have places to find these: been initiated or published since this text was completed. Also, there may be ongoing or soon-to-be-published research that 1. In Massage Research sections, in Parts II and III; is not indexed, so it is good to search regularly for a topic of 2. In Possible Massage Benefits sections, in Parts II and III; interest. 3. In the discussion of massage and circulation (see “Increased If a few studies or reviews are published on a condition, Circulation,” Chapter 2); they are referenced by last name and date. If there are too 4. On Decision Trees, whenever “circulatory intent” is used many studies on a condition to list, a few selected studies are referenced. The full research citations are in the online instead of “circulatory massage,” to reflect the stated pur- bibliography. pose of massage rather than an evidence-based fact. Under each full discussion of a medical condition, the For each medical condition in this book, a brief summary of Possible Massage Benefits section is devoted to the benefits of relevant massage research appears in the Massage Research massage that may or may not have been established by research, section. If the relevant massage research is indexed in PubMed, or may never be studied in formal research. Instead, common the Massage Therapy Foundation database, or the NIH sense and clinical experience tell us how we might help some- RePORTER database at the time of this writing, it appears one with a skin condition, a heart condition, HIV/AIDS, or MS. in this section. If nothing appears in these databases, then
Telling Stories 81 These summaries of benefits also come from client testimonials tell them, or because clients continue to come for massage. Few or the author’s clinical observations over the years. Often thera- people need research to convince them that they need to sched- pists know how helpful massage can be, simply because clients ule another session; their own experiences tell them so. The Limitations of Research Research evidence is highly valued in the medical world, and this framework. Indeed, some experiences of massage—relief of using established scientific methods to study massage continues pain, care, connection, nurturing, healing—are some of the deep- to yield interesting and useful perspectives on massage therapy. est, most personal and multidimensional experiences possible. Still, research cannot tell us everything about massage. Some of the nuances of massage therapy might never be captured in massage research. Research has its place; but, by studying As compelling as research is, its focus on cause and effect things too closely, it also has the potential to reduce an individual reflects a Western thought process, and a linear approach to the story to pieces that ignore the wholeness of the experience. search for truth. Not all human experiences lend themselves to Telling Stories Every practitioner has an anecdote to tell, even after only a few At some point, research, a growing collection of stories, may months in practice. Personal experience is powerful. Even if no tell us much more about massage than we already know. But research supports massage for a certain condition, a therapist as limited as our present evidence-based knowledge is, we do may have a single story or a handful of stories to share from his see massage at work in people’s lives every day. After massage, or her practice. One therapist could tell about a client’s chronic many people are more at ease in themselves, and feel more headaches improving, or someone else’s back pain getting bet- clearly seen, heard, and known. The support of massage can ter. Another therapist might tell about increased mobility, or be carried out the door, toward whatever challenges the client improved sleep. If the therapist carefully guards her clients’ con- faces next. Quiet, unassuming massage can do wonders for fidences, withholding any identifying information, she may share people as they move their bodies through their lives. These these stories, and people respond to them. When someone asks, are things that we know in our minds, but also in our hearts “How can massage help me?” he or she might be more interested and hands. in a single account of massage therapy than a battery of studies. SELF TEST 1. Describe four ways that research can support the massage can a therapist locate research studies that are currently in profession. progress? 6. Why is a control group important in clinical research on 2. Define best practice research. How can it influence the massage? Give an example. practice of massage? 7. What is the difference between a wait-list control, an attention control, and a crossover design? 3. List three common claims made about massage that are 8. Why can it be challenging to provide a sham control, or to not supported by research. How can massage therapists blind the research subjects, in massage therapy research? more correctly summarize the state of knowledge about 9. Suppose you have a question about whether and how a cli- each of the claims? ent’s low back pain is responding to massage after several weekly sessions. Formulate the question to your client in 4. What is the difference between a narrative review of VAS and VRS formats. research and a systematic review? Define each term. 10. What is the difference between a case report and a case Which one is a higher level of evidence? series? Where do they appear on the levels of evidence? 5. Where can a therapist find a database of published mas- sage research in the medical literature? Which organization publishes systematic reviews of medical research? Where For answers to these questions and to see a bibliography for this chapter, visit http://thePoint. lww.com/Walton.
Chapter Part II Conditions
Chapter 7 Skin Conditions Depth must be hidden. Where? On the surface. Such sustained skin contact can heighten a therapist’s concern when infection is a possibility. Often, infection control —HUGO VON HOFMANNSTHAL practices can be borrowed from nursing and physical therapy, since nurses and PTs also touch the skin a great deal during Of all the systems of the body, perhaps the one that is most patient care. familiar to a massage therapist’s hands is the integumentary system. The skin is the body’s surface. It protects what lies In this chapter, four conditions are discussed at length. The beneath, cleanses the body, prevents water loss, and provides conditions are: a barrier to infection. While working through the skin to the muscles and fascia beneath, therapists notice changes in client ● Psoriasis skin temperature, color, and texture over time. ● Acne ● Oral and genital herpes (herpes simplex 1 and 2) This vital body system, which functions to help keep the ● Scabies rest of the body healthy, can itself be challenged—externally, by sources of infection, injury, and allergy, and internally, by In addition, a full discussion of eczema (atopic dermatitis, or hormonal and genetic factors. Therapists are responsible for AD), including a Decision Tree, may be found online at http:// considering the health of their own skin, as well as that of their thePoint.lww.com/Walton. clients, when making massage decisions. Conditions in Brief addressed in this chapter are: Acne The conditions introduced in this chapter represent a spec- rosacea, athlete’s foot (tinea pedis), basal cell carci- trum of common skin conditions, which include inflammation, noma, boils, cellulitius, cuts and abrasions, folliculi- infection, and breaks in the skin. Skin conditions often involve tis, hives (urticaria), impetigo, jock itch (tinea cruris), a specific type of lesion, a general term describing any change lipoma, lice (pediculosis), melanoma (malignant mela- in tissue that makes it different from its normal state. Although noma), methicillin-resistant Staphylococcus aureus a lesion can occur in any tissue, it is most visible on the skin, (MRSA), moles, nail fungus (tinea unguium), poison and is particularly apparent when it is open and the skin is no ivy/oak/sumac, pressure sores (decubitus ulcers), ring- longer intact. worm (tinea corporis), shingles (herpes zoster), skin tags, squamous cell carcinoma, sunburn, and warts (verrucae From such close, sustained contact with the skin, a massage vulgaris). therapist is often the first to notice a lesion on a client’s skin that needs attention from a physician. General Principles Skin lesions can come from many conditions, and several with a gloved hand or massage lubricant. Open lesions, principles can be applied from Chapter 3: the Inflammation regardless of the cause, are vulnerable to dirt and normal Principle, the Ask the Cause Principle, and the Waiting for a flora (bacteria and other resident microorganisms on the Diagnosis Principle. Along with these principles, three new skin) that can be introduced by direct contact. Therapists principles are introduced: must be careful to minimize the transmission of known and undiagnosed infections. 1. The Body Fluid Principle. If it’s wet and it’s not yours, don’t 3. The Ask If It’s Contagious Principle. Before making touch it. Borrowed from emergency medicine, this serves contact with a client’s body, find out whether a skin as a reminder that body fluids can transmit infection from lesion is contagious and how it is spread. Some conta- person to person, even when there are no symptoms of gious conditions, caused by viruses, fungi, bacteria, or infection. This is particularly relevant to fluid from open parasites, could be passed to the therapist by contact. lesions on the skin. If it is inflamed, painful, or itchy, there is an additional red flag. Other conditions, such as poison ivy, are not caused 2. The Open Lesion Principle. Do not make contact with an by microorganisms, but any plant oil remaining on the skin open lesion. This is not only an extension of the Body Fluid could be transmitted elsewhere on the client, or to the Principle, designed to protect the therapist from infection, therapist, causing a rash (see “Follow-Up Questions About it also protects the client from microorganisms entering the Infection,” Chapter 4). open skin. Regardless of the cause of the lesion, avoid mak- ing skin-to-skin contact. Also avoid touching an open lesion 83
84 Chapter 7 Skin Conditions Psoriasis In psoriasis, the cycle of skin cell growth is accelerated—from cells, reducing inflammation. First line therapy refers to the the normal time frame of 28–30 days to just 3–4 days. As a initial treatment approach for a condition; if the treatment fails result, layers of skin cells in various stages of growth “pile up,” or stops working, subsequent treatments are called second line giving the skin a thickened appearance. therapy, and so on. For psoriasis, first line therapy is topical creams, applied to the skin surface at the site. Ultraviolet light ● BACKGROUND therapy is also used. Psoriasis is treated with anti-inflammatories, topical corticosteroids (see chapter 21), and, in some cases, a Psoriasis seems to be caused by a problem in the immune variety of stronger oral or injected medications with varying side system involving overactive cells, inflammation, and the rapid effects. Often, treatments are rotated, in which an oral treatment formation of new skin cells. The most common type of psoria- will be used for a number of months, then stopped while a topi- sis is plaque psoriasis (80% of cases). It often occurs in cycles: cal treatment is used. This can give the individual’s body a break periods of flare-ups and remission. The flare-ups are triggered from some of the side effects of stronger oral medications. by stress, hormonal changes, injury to the skin, some prescrip- tion drugs, and a compromised immune system. Topical preparations are administered as a single type of medication or a combination of medications. Most of these Signs and Symptoms have minimal side effects except for skin irritation. These include: coal tar, salicylic acid, anthralin, calcipotriene (a syn- As shown in Figure 7-1, psoriasis can look like a dramatic, dis- thetic vitamin D3), retinoid, and steroid medication. tinct, scaly rash. It is raised, with silver and red scales. Psoriasis tends to appear on the elbows, knees, scalp, and trunk, but it Systemic medications may be used along with topical can develop anywhere. It may be accompanied by pain, itch- preparations. A systemic medication is any drug that affects ing, or cracking of the skin. the whole body, by being distributed through the bloodstream. There are several ways to administer a drug systemically, but Complications the typical routes are oral, by injection into the muscle or skin, or by introducing it directly into a vein through an intrave- Plaque psoriasis has fewer complications than rarer forms. nous (IV) line. Systemic drugs for psoriasis include retinoids Rarer forms, such as guttate, pustular, inverse, or erythroder- (such as Soriatane), cyclosporine (Neoral), methotrexate, and mic psoriasis are characterized by serious lesions and a more biologic therapy, also called immunotherapy. Biologic ther- complex clinical picture. Other complications may be present, apy acts on the immune system to turn down the inflammatory such as open and weeping lesions, inflammation, and fever. mechanisms that cause psoriasis. Psoriatic arthritis develops in about 25% of cases, usually Most systemic drugs for psoriasis act on the immune system well after the skin lesions have appeared. This form of arthritis in some way; in higher doses, cyclosporine is used to prevent tis- causes swelling, pain, and stiffness, usually in hands, knees, sue rejection, and methotrexate and biologic therapies are used and feet, sometimes the spine. Fingers and toes can be so in the treatment of cancer and other conditions. Although they swollen that they have a “sausage-like” appearance. Psoriatic are monitored closely, these drugs come with numerous pos- arthritis can be extremely painful. It can also appear without sible side effects and complications, and individuals are moni- any corresponding skin lesions. tored closely for toxic effects, which can include kidney damage, liver damage, and elevated blood pressure. Biologics can cause Treatment mild flu-like symptoms and respiratory infection. Treatment depends on the type of psoriasis. Treatments typically ● INTERVIEW QUESTIONS interrupt the accelerated cycle of growth and the pile-up of skin 1. What kind of psoriasis is it? FIGURE 7-1. Psoriasis. (From Goodheart HP. Goodheart’s Pho- 2. Where is it? toguide to Common Skin Disorders, 2nd ed. Philadelphia: Lippincott 3. Does it itch or hurt? Williams and Wilkins, 2003.) 4. Do you want some kind of massage or contact over the area? 5. How does the area respond to contact, pressure, or friction? 6. How does the area respond to lubricant? Do you have a preferred lubricant that you use there? 7. Does the skin in the area tend to crack? 8. Is there any arthritis associated with the psoriasis? 9. How is your psoriasis or psoriatic arthritis treated? 10. Are there any side effects or reactions to treatment? Tell me whether your treatment affects your skin, kidney func- tion, or liver function. ● MASSAGE THERAPY GUIDELINES Plaque psoriasis is the most common form that the therapist will encounter in practice. If a client is unsure how to respond to question 1, ask if their doctor said that it is a common
Psoriasis 85 Psoriasis Massage Therapy Guidelines Medical Information Pressure level 2 maximum at site; avoid dislodgining deeper scales Essentials that could cause bleeding; avoid Thickened, red skin with silvery lubricant that irritates the area or gray scales No friction or circulatory intent at site Itching, pain No contact or lubricant at site Cracking of skin Pressure level 1–2 maximum at site; avoid joint movement that Complications aggravates pain; avoid general Psoriatic arthritis of joints– pain, stiffness, circulatory intent sometimes profound swelling Avoid contact with topical Medical treatment Effects of treatment medication (use gloves if touching area); if massaging over the area, Topical Irritation at the use pressure 1 max to avoid medications (coal site of application rubbing in medication and speeding tar, salicylic acid, absorption. anthralin, If topical corticosteriod use has calcipotriene, resulted in skin thinning and retinoid, cortico- bruising, use gentle pressure steroid) (typically 1–2 max) Follow Medication Principle (see Strong oral Numerous strong Chapter 3) medications side effects (methotrexate, possible See Table 21–1 for liver and kidney retinoids, complications and massage therapy cyclosporine) Decreased liver guidelines or kidney function Injected biologics No general circulatory intent if Respiratory symptoms infection; mild flu-like symptoms No friction or circulatory intent at site until medication absorbed Irritation at injection site FIGURE 7-2. A Decision Tree for psoriasis. form—plaque psoriasis. If the client has another type of Question 8 is used to identify psoriatic arthritis. If a client psoriasis, ask for more details about signs, symptoms, and has psoriatic arthritis, it can be very painful and swollen, in complications such as open, weeping lesions, inflammation, some cases similar to rheumatoid arthritis (see Chapter 9). Use and fever. Adapt to open skin (see Figure 7-2), and follow the gentle pressure (2 max), if any, on affected areas, and avoid inflammation principle. Medications for other psoriasis types joint movement that aggravates discomfort. Also, avoid general tend to be stronger than those for plaque psoriasis. Investigate circulatory intent during a flare-up of psoriatic arthritis, as the your client’s condition for these signs, symptoms, and com- client may feel unwell. plications. See the bibliography online at http://thePoint.lww. com/Walton for places to look for more information. Questions 9 and 10 about treatment can identify one or more of a range of medications. If topical medications are Questions 2–7 guide you to a possible pressure, friction, used, contact at the site may be contraindicated altogether lubricant, or contact restriction at the affected site. If the because of irritation at the site of application, or because the area is painful or itchy, then friction and circulatory intent are condition itself is severe. If contact is not prohibited, and is contraindicated at the site. If the area is simply thickened and welcome, then avoid rubbing in topical medication and speed- red, gentle massage at a maximum pressure level of 2 may be ing up the absorption; a pressure level 1 is the maximum to use welcome, but avoid aggravating the condition; use a lotion or at the site. Also, use gloves when contacting the area to avoid oil that does not irritate the area. If too much massage pres- absorbing the medication into the skin of the hands. sure causes peeling away of the scales of psoriasis, it may cause bleeding. If there is cracking of the skin, then contact and If the client is taking oral medications for psoriasis, follow lubricant are contraindicated over the area. the Medication Principle from Chapter 3. In particular, be alert for diminished kidney or liver function. See Table 21-1
86 Chapter 7 Skin Conditions for relevant signs, symptoms, and massage therapy guidelines indexed in PubMed or the Massage Therapy Foundation for renal and liver toxicity. Research Database. The NIH RePORTER tool lists no active, federally funded research projects on the topic in the United The Medication Principle. Adapt massage to the condition States. No active projects are listed on the clinicaltrials.gov for which the medication is taken or prescribed, and to any database (see Chapter 6). side effects. ● POSSIBLE MASSAGE BENEFITS If the client is using injected biologics, the newer therapies for psoriasis, ask about flu-like symptoms or respiratory infec- If contact is not contraindicated, it may feel good to the client tions. If either of these is present, they are likely to be mild, but to feel the massage therapist’s hands simply resting directly on it is still a good idea to avoid general circulatory intent. Always affected areas, or through a drape. Firm pressure without fric- avoid friction and circulatory intent at a recent injection site tion may help the client manage the itching and pain of pso- until the medication has had plenty of time to be absorbed. riasis, and reach the underlying muscles without irritating the area. Remember that stress is a psoriasis trigger, so any mas- ● MASSAGE RESEARCH sage work that reduces stress could play a role in preventing flare-ups. Finally, lesions can be quite distinct and dramatic, As of this writing, there are no randomized, controlled trials, and a cause of self-consciousness. A therapist can offer not published in the English language, on psoriasis and massage only compassionate, respectful touch, but also a gentle, unal- armed demeanor as the lesions are uncovered in the session. Acne Vulgaris Acne vulgaris is the scientific name for common acne; the maintenance. These can cause increased photosensitivity, mild name distinguishes it from a related condition, acne rosacea nausea, and mild diarrhea. Oral retinoids such as Accutane may (see Conditions in Brief). Acne is the eruption of pimples have side effects such as dryness and joint pain. Because they can caused by the interaction of the oil-producing glands of the skin, also affect the liver, periodic liver function monitoring is part of hormones, normal flora on the skin, and the immune response. the therapy. There is a risk of severe birth defects, and women of childbearing age are urged to use two forms of birth control while ● BACKGROUND taking oral retinoids. Oral contraceptives are used when hormonal imbalances play a role in acne. These medications may cause Acne lesions most often occur on the face and the shoulders, but weight gain and breast tenderness, among other side effects. can appear on other surfaces, as well. It is most common in ado- lescents, but younger children and adults can also develop acne. ● INTERVIEW QUESTIONS Signs and Symptoms 1. Where is the acne? Is it mild, moderate, or severe? 2. Have you had massage over the area before? How does the Acne can range in severity, presenting as a few isolated come- dones (whiteheads or blackheads) to the deepest lesions, area respond to contact, pressure, and different lubricants? inflamed areas known as cystic acne. The most severe presen- 3. If you are treating it, how? tation can be painful and cause scarring. 4. How does the treatment affect you? Complications ● MASSAGE THERAPY GUIDELINES Psychosocial issues including poor self confidence and self In general, be sensitive to possible effects of acne on body image, esteem are common, especially with severe acne. especially if it is severe, or if scarring remains years later. Treatment An area of acne is an area of inflammation, and friction or circulatory intent may aggravate the inflammation. And Mild acne is treated topically with over-the-counter prepara- although there is no absolute maximum pressure level for acne, tions aimed at drying up oil, removing dead skin cells, or killing the pressure should be gentle at the site. Some lubricants may bacteria. Over the counter (OTC) refers to medications that irritate the area and worsen the acne, as well. Question 1 helps are available without a prescription. Acne preparations contain establish the location and severity of the inflammation. benzoyl peroxide, salicylic acid, or other ingredients. These have few side effects: at most, some people experience uncom- That said, some individuals will want contact or even deep fortably dry or irritated skin. If OTC topicals are not effective, pressure on the muscles that are deep to the region of acne. acne is treated with prescription topicals: antibiotics and retin- This is especially true on the shoulders or back. Individual oids. These also tend to cause few side effects, but peeling, preferences for lubricant can vary. Some want lotion instead irritation, and increased photosensitivity may occur. Often, of oil, or even very little lubricant at all because of their expe- combinations of topical preparations are used with success. rience that it aggravates the acne. Some clients prefer lots of lubricant, to ease friction on the area. If topical preparations do not work, systemic medications may be tried, such as antibiotics, retinoids, and oral contracep- Requests for pressure in the affected area must be considered tives. Oral antibiotics (such as tetracycline, erythromycin) may carefully. For example, a gentle amount of pressure at levels 1 be prescribed, but may be required for months or years for or 2 might aggravate inflammation for one client, and should be avoided. However, it might not aggravate the inflammation
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